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Introduction Intramedullary nailing (IMN) is currently considered the gold standard in the surgical treatment of tibial shaft fractures in adult patients. In this case-control comparative study, we aimed to compare the efficacy of minimally invasive plate osteosynthesis (MIPO) and IMN in treating tibial shaft fractures. Materials and methods The clinical and radiological outcomes, such as a modified trauma scale, operation time, fracture healing, rate of re-operation, and complications such as malunion, nonunion, shortening, and infection were assessed between IMN and MIPO for the treatment of tibial shaft fractures. Results Seventy-three skeletally mature patients who underwent IMN (group I) or MIPO (group M) for a closed extra-articular tibial shaft fracture (AO/OTA type 42) from June 2010 to May 2016 were retrospectively reviewed. The mean age was 51.16 (18~79) years, and the mean follow-up period was 22 (12~50) months. Bony union was achieved in all cases but one for each group - group I (35 cases) and group M (36 cases) (p > 0.05). Mean callus formation was observed in 12 (8 – 16) weeks in both groups (p > 0.05). There was no significant difference in operative time, hospital stay, bone healing, and the rate of complications among the two groups (p > 0.05). There was also no postoperative difference in functional evaluation between the two methods (p > 0.05). Conclusions No discrepancy was found in radiological and clinical outcomes between IMN and MIPO for tibial shaft fractures. It can be concluded that both IMN and MIPO are equally effective treatment modalities for tibial shaft fractures.

Since its conception in 1989, minimally invasive plate osteosynthesis (MIPO) has gained widespread popularity. It has been studied in over forty countries with most of the publications originating from Asia, Europe and North America. This review aims to describe the scientific path of MIPO from the very beginning to where it stands in current day times; study the pattern and contributing factors influencing its global spread. Finally, the up to date evidence is discussed with regard to several anatomical regions in which MIPO is mostly used. In the meantime, MIPO treads steadily towards accomplishing the same or better outcomes for more and more indications with the goal to leave a smaller surgical footprint to allow for undisturbed bone healing.

Introduction The necessity for reduction and fixation of posterior malleolus fractures remains under debate. Therefore, we assessed the functional outcome and quality after plate osteosynthesis of the posterior malleolus, identified the main drivers of outcome and aimed to determine which patient and fracture type are eligible for plate osteosynthesis of the posterior malleolus. Materials and methods A prospective patient cohort of 50 patients with an ankle fracture including the posterior malleolus underwent plate osteosynthesis via a posterior approach, and was compared to a retrospective patient cohort of 85 consecutive patients who did not. Twenty-five demographic, operative and postoperative characteristics were assessed. Outcome was recorded using questionnaires: AOFAS, EQ-5D, EQ-5D-VAS, EQ-5D-TTO, sensory nerve‐associated complications, and flexion deficit of the hallux. Results Direct reduction and plate osteosynthesis of posterior malleolus fractures was inferior to non-operative treatment. Subanalysis of trimalleolar fractures revealed that the outcome of plate osteosynthesis was equal. Both fracture type and plate osteosynthesis were independent drivers of the outcome; Haraguchi type 3 posterior malleolus fractures were associated with the best functional outcome and quality of life scores. Comorbidity, age, postoperative complications and reintervention largely determined the outcome. Up to 30% of the patients reported (temporarily) flexion deficit of the hallux and 38% numbness at the lateral side of the foot. Conclusions There is no indication for routine plate osteosynthesis of all posterior malleolus fractures. Careful patient selection, less invasive surgery and modified postoperative rehabilitation seem mandatory to improve the outcome and prevent adverse effects.

Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications.76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years).Mean Constant score was 74 (range to 28-100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed.Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing.

Background Surgical treatment of extra-articular distal-third diaphyseal humeral fractures is controversial in terms of surgical approach and position of implant. The aim of this study is to evaluate the clinical and radiological outcomes of a modified application of the proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures. Materials and methods A total of 23 patients with extra-articular distal humerus fractures were treated using either open plating or the minimally invasive plate osteosynthesis (MIPO) technique with upside down application of the PHILOS plate. Fracture configuration, number of screws in the distal fragment, and time to union were analysed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up. Results Fracture union was obtained in all patients at a mean postoperative time of 20.8 ± 2.9 weeks. The mean shortest and longest cortical lengths were 50.7 ± 14.0 mm and 85.2 ± 12.4 mm, respectively. The average number of screws in the distal humeral fragment was 5.6 ± 0.7. No statistically significant correlation was observed between the shortest cortical length and number of screws in the distal fragment (p = 0.224) or between the longest cortical length and the number of screws in the distal humeral fragment (p = 0.956). The average MEPS was 97.6 (range, 75–100). No postoperative complications that required reoperation were occured. Conclusion A modified anterior application of the PHILOS plate in extra-articular distal-third diaphyseal humeral fracture showed satisfactory outcomes, so it is an alternative when considering the ability to increase plate-screw density with locking screw fixation in a distal humeral fragment. Level of evidence Therapeutic level IV, case series.

Background Different stand-alone cerclage configurations and their optimal twisting techniques have been investigated over the years. This study tests for the stabilizing effect of different supplemental cerclage materials in combination with locked plating of distal tibia fractures. Methods Locking plate fixation of a distal tibial spiral fracture was tested as stand-alone and with supplemental cerclage materials (one cable, two cables, wire, fiber tape). Construct stiffness and fracture gap movements were investigated under quasi-static and dynamic loads and compared to the stand-alone locking plate. Results With each of the tested cerclages, stiffness was significantly higher than for a solitary plate osteosynthesis. Most reduction in fracture gap movement was achieved by cable cerclages, followed by double-looped wire and double-looped fiber tape cerclages. Under dynamic loading an additional cable cerclage reduces excessive gap movement. Conclusion Compared to solitary plate osteosynthesis all supplemental cerclage materials were generally superior with reduced fracture gap movements whereas cable cerclages showing the greatest stabilizing effect.

Management of posterior tibial plateau fractures has gained much interest over the past few years. Fracture morphology, trauma mechanism, and soft-tissue injury have been identified as the key factors determining the treatment strategy and outcome. We provide a rationale for the operative management of posterior tibial plateau fractures by discussing the interplay between fracture morphology, trauma mechanism, and soft-tissue injury. The trauma mechanism has proven to be an important tool, not only to understand fracture morphology, but also to assess concomitant soft-tissue (i.e. ligamentous) injury. Subsequently, soft-tissue injury might play a role in future classification and diagnostic work-up of tibial plateau fractures, particularly in fractures with posterior involvement. Plate osteosynthesis using a posterior approach is safe and should be considered routinely in coronal fractures of the posterior tibial plateau, as illustrated.

Introduction Over the last few years, treatment of mid-shaft clavicle fractures seems to have shifted from conservative to surgical. Our study reports the results of plate osteosynthesis of mid-shaft clavicle fractures and compares them with literature. Materials and methods A retrospective cohort study was conducted on 32 patients with mid-shaft clavicle fractures treated with plate and screws between January 2009 and December 2014. All the patients followed the same post-operative rehabilitation program with radiographic and clinical evaluation (DASH score and Constant score) at a minimum follow-up of 24 months. Results All the patients healed clinically and radiographically, without deformities or non-unions, with complete and early functional recovery and return to their pre-injury sport activities. At one year follow-up the mean Constant Score was 93.8 (SD 4.8) and the mean DASH score was 42 (SD 5.0). Conclusions Osteosynthesis with plate and screws of mid-shaft clavicle fractures allows not only restoration of the anatomy, but also early recovery of shoulder function. For this reason, such surgical treatment should always be considered when facing this particular fracture group, also in accordance with recent literature.

Introduction The aim of this study was to perform MIPO of the distal tibia from a dorsomedial and dorsolateral approach and to evaluate their feasibility and risk of injury to adjacent anatomical structures. Material & Methods A total of 18 extremities from 9 adult human cadavers was included in the study. In each cadaver, one lower leg underwent application of a 12-hole 3.5 LCP metaphyseal plate from the medial and the further one from the lateral approach. For the medial approach, a 4 cm skin incision was performed at the tibial border of the Achilles tendon, starting from 1 cm proximal to its insertion point at the calcaneal tuberosity. Entrance was gained between the medial border of the flexor hallucis longus tendon and the medial neurovascular bundle. Regarding the lateral approach, the skin was incised over a length of about 4 cm at the lateral border of the Achilles tendon, approximately 1 cm proximal to its insertion point. Entrance was gained between the Achilles tendon and the peroneus brevis muscle. The plates were inserted in direct bone contact in a proximal direction and the proximal and distal ends were fixed. During dissection, the proximal and distal holes beneath the crossing points of the neurovascular bundle and the plate were noted. The distal and proximal intersection points of the neurovascular bundle and the plate were measured with reference to the distal border of the plate. Results Concerning the medial approach, the neurovascular bundle was on median located between the 6th and 11th plate holes starting from distal. The bundle intersected the plate distally at a mean height of 65.8 mm and proximally at 156.8 mm on average. For the lateral approach, the neurovascular bundle was situated between the 6th and the 12th plate hole from distal. It crossed the plate distally at a mean of 61.0 mm and proximal at a mean height of 153.9 mm. In none of the cases, lacerations of the neurovascular bundle were observed. Conclusion In conclusion, MIPO from the dorsomedial and dorsolateral approach are both safe procedures as indicated by our study.

Osteosynthesis has evolved theoretically and practically throughout its evolution. Similar to trends in other surgical fields, surgical techniques in fracture fixation, such as minimally invasive plate osteosynthesis (MIPO), have moved from large dissections to more tissue sparing methods. These plating techniques have been developed for a variety of bones, but more universal clinical adoption will rely upon improved clinical outcomes. The current review will describe minimally invasive techniques, evaluate their rationale, and summarize evidence for their efficacy.

Background Currently Minimally Invasive Plate Osteosynthesis (MIPO) technique for tibial shaft fracture management has gained wide attention. However, an increased intracompartmental pressure after the plate insertion may result in postoperative acute compartment syndrome. We reported the difference of immediate effect of percutaneous plate insertion using 2 approaches of MIPO technique on anterior compartment pressure of the legs. Materials and methods Eight soft cadaveric legs (one female and three males) without previous history of skeletal trauma or surgery were infused with normal saline to create the sustained intracompartmental pressure of 20 mm Hg in all four compartments. The Synthes® 4.5 mm 11-hole Narrow Locking Compression Plate was inserted via anteromedial and anterolateral approach. Anterior compartment pressure was measured by portable digital monitoring device through side-port needle (Stryker® Intracompartmental Monitoring Device) before and after plate insertion for each approach. Results By using anteromedial approach, a mean of anterior compartment pressure was increased by 0.375 mm Hg after plate insertion (5 of 8 legs had no change in pressure and the remaining 3 resulted in 1 mm Hg pressure elevation). For anterolateral plate insertion, all of the 8 legs had an elevation of anterior compartment pressure with a mean of 3.5 mm Hg (ranged from 2 to 6 mm Hg). Conclusions When both approaches were compared to each other, the anterolateral plate insertion resulted in higher intracompartmental pressure elevation of the anterior compartment than the anteromedial approach. Surgeon should be more aware of acute compartment syndrome when considering the anterolateral approach in treating close tibial fracture. However, in patients with suspected acute compartment syndrome, close observation and continuous monitoring of the intracompartmental pressure is still imperative for all healthcare provider.

Background The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. Methods A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. Results Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p = 0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. Conclusions Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

Background In recent years, Minimally Invasive Plate Osteosynthesis (MIPO) has been gaining popularity in the treatment of distal tibia fractures, because it is a minimally invasive surgical procedure, thus it limits the soft-tissues damage. This prospective randomized study aims to assess the impact of lag screw in the healing time of distal tibia fractures treated with MIPO technique, in a six-month follow-up. Methods Patients between 20 and 70 years of age with distal tibial fracture, type 43-A according to AO/OTA classification system were included. All the patients were randomized into two groups, to receive MIPO without lag screw (Group-A) or MIPO with percutaneous lag screw (Group-B). Patients were followed clinically and radiographically at 3, 6, 12 and 24 weeks postoperatively. The main outcome measure was the time needed to achieve the painless full weight-bearing (FWB) after surgery. Unpaired t-test after ANOVA (analysis of variance) was performed to assess AOFAS score differences between the 2 groups at each follow-up. Pearson correlation test also was performed. The tests were two-tailed with a confidence level of 5%. Results 42 patients (24 male and 18 female, mean age 49.54 years old, range 25–80) were recruited. A significant shorter mean time until painless FWB (p = 0.016) was observed in Group-B (11.22 ± 3.06 weeks) compared with Group-A (13.48 ± 2.42 weeks) ( Table 2 ). The mean AOFAS score was comparable in patients treated with (Group-B) and without lag screw (Group-A) at all follow-ups. Conclusions This prospective randomized clinical study has shown that the use of lag screw in distal tibia fractures treated with MIPO technique speeds the fracture healing, thus shortening the time needed to achieve FWB.

Introduction Minimally invasive plate osteosynthesis (MIPO) using locking plates has been used in distal femur fractures, but various problems, such as nonunion, malalignment, and implant failure, have been reported. Simple fractures sometimes have poorer outcomes than complex fractures. We studied elderly patients with simple fracture patterns who underwent open reduction followed by placement of a single positional screw to hold the reduced interfragmentary gap, and compared these cases with patients who underwent surgery using conventional MIPO techniques. Patients and methods A retrospective analysis was conducted on 80 cases of patients with distal femur fractures and simple fracture patterns (33-A1, A2, and C1). The mean age was 74 (60–90) years, and the mean follow-up period was 14 (12–25) months. Group A included 40 patients who underwent conventional MIPO technique while Group B included 40 patients who had surgery using positional screws. Interfragmentary gaps in Group B were reduced using percutaneous reduction clamps, and cortical screws were inserted to sustain the reduction. Then, locking plates were inserted using conventional MIPO techniques. Results Bony union was achieved in all 80 cases, mean initial callus formation was observed in 11 weeks (8–13 weeks), and radiological union was observed in 27 weeks (15–54 weeks). Time to initial callus formation was not different, but radiologic union was achieved in 30 weeks (18–54 weeks) for Group A and 25 weeks (15–41 weeks) for Group B (p = 0.006). No differences were seen in clinical function at 1 year (p = 0.580). Five cases of malalignment occurred in Group A (p = 0.021). The rate of union during the 1-year period was significantly higher in group B than in group A (p = 0.002). Conclusions In a distal femur fracture with a simple fracture pattern, using positional screws to sustain the reduced interfragmentary gap may achieve a more rapid union by reducing fracture gap. Though functional differences were not seen in follow-ups, patients can be expected to return to their normal lives earlier as union is achieved in a shorter time. Performing MIPO using positional screws to sustain the reduced interfragmentary gap after fracture reduction will be helpful in the treatment of simple femoral fracture.

Objectives The current biomechanical work compares the symphyseal and sacroiliac stability obtained with two systems of bone osteosynthesis. The two methods of fixation compared were the 6-hole suprapubic non-locked plate and pubic fixation with two cannulated screws, a novel technique that can be applied percutaneously in the clinical practice. The aim of this study was to examine the validity of the use of two-cannulated-screws osteosynthesis in order to minimize the secondary effects of open fixation, especially in patients in whom an open reduction is contraindicated. Materials and methods A biomechanical study was designed in 9 fresh, human pelvis specimens, simulating an AO B1.1 type injury, using both fixation systems sequentially in each specimen. In both parts of the test, the specimens were subjected to an axial load of 300 N. Displacements and rotations between the different pelvic elements were studied by means of a discrete set of points. The absence of differences between the two systems has been set as the null hypothesis. Results There were significant differences in favor of the cross-cannulated screws in most of the displacements measured at the pubic symphysis and sacroiliac joint. Conclusions Fixation of the AO B1.1 type fractures with cross cannulated screws restores the biomechanical behavior of the pubic symphysis, obtaining better stability than fixation with the 6-hole non-locked plate. To date, no comparative, biomechanical studies have been conducted with these two systems of osteosynthesis. This study demonstrates that cross-cannulated screws fixation of the pubic symphysis in AO B1.1 pelvic fractures should be considered as an alternative to the conventional plating system.

Objective The objective of the study was to evaluate the effectiveness of the posterolateral minimally invasive plate osteosynthesis (MIPO) method for managing distal tibial or tibial shaft fractures with severe anterior and medial soft tissue injuries. Materials and methods Five consecutive patients with three distal tibial and two tibial shaft fractures (three open fractures) at a level-1 trauma and tertiary referral center were retrospectively reviewed. All patients were definitively treated and followed to bone union. Main outcome was measured by American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score, complications, and bone union on radiographs. Results The average follow-up period was 15.8 months (range, 12–24 months). The average AOFAS score was 88.2 (range, 81–90). There were no complications, such as incision breakdown, deep infection, or impingement of the flexor hallucis longus tendon. Bone union was achieved in all cases. Conclusions Posterolateral MIPO is a feasible option when treating these fractures, especially in cases with severe anterior and medial soft tissue injuries.

Introduction The purpose of this study was to determine the effectiveness of circular external fixation (CEF) as a definitive treatment option for patients with complex tibial plateau fractures (Schatzker VI) compared with the outcomes of a fixed angle locking plates’ group. Methods Level III evidence. Retrospective, comparative study in a Level I Trauma Center. Fourteen patients treated with CEF (Group A) were compared to fourteen patients treated with minimal invasive angle locking plates (Group B). The mean time from fractures to surgery was 19 days for Group A with a mean ISS of 24 and 7 days for Group B with a mean ISS of 14. The main outcome measures were clinical and radiographic. Results Complete union was obtained in Group A at an average of 22 weeks and at 17 weeks in Group B. Two patients developed non-union, one in each group. Normal alignment was observed in both groups, no statistical differences were observed in Paley’s anatomical posterior proximal tibial angle (aPPTA) and mechanical medial proximal tibial angle (mMPTA) between two groups. Results based on the Association for the Study and Application of the Method of Ilizarov criteria for Group A: 71% excellent and 29% good as far as bone outcomes are concerned and as 57% excellent, 37% good, and 7% fair for functional outcomes. Conclusions Definitive fixation with circular external fixator is effective in complex Schatzker VI tibial plateau fractures. Advantages include maintaining the frame till union, reduced risk of infection, early mobilization, restoration of the normal lower extremity alignment, versatility, and improved union rate in patients with multiple traumatic injuries, infection, and soft tissue injuries.

Objectives The best fixation method for open tibial fractures has long been a matter of debate, many studies have recommended the use of intramedullary nails over external fixation for treating such fractures, recent studies also showed favorable results for the use of plates in managing open tibial fractures. However, there are very few (if any) reports in the literature comparing the use of minimally invasive plate osteosynthesis to reamed intramedullary nails in the fixation of open tibial fractures. The aim of this study was to compare the safety & efficiency of minimally invasive plate osteosynthesis to reamed intramedullary nails in treating open tibial shaft fractures. Design A single-center, parallel group, prospective, randomized study. Setting Academic Level 1 Trauma Center, during the period from October 2014 to December 2016. Patients A total of 60 patients with open tibial fractures were randomized to reamed intra-medullary nails (R-IMN) (group A) or minimally invasive plate osteosynthesis (MIPO) (group B). Outcome measurement Patients were assessed for union (clinical & radiographic) & complications (e.g.; non–union, infection). Results No statistically significant differences were found between the 2 methods in term of the incidence of infection or non-union. Time to full union was shorter for the R-IMN group when compared to that of the MIPO group & that was found to be statistically significant. Conclusion MIPO technique has equal safety to R-IMN technique in treating Gustilo-Anderson type I, II and III-A open tibial shaft fractures, as both techniques have similar rate of infection & non-union. These findings suggest that the MIPO technique can be considered a valid treatment alternative for such fractures. Level of evidence Level II, Therapeutic study.

Background Current literatures describe good clinical outcomes of acute displaced fracture of clavicle treated with minimally invasive plate osteosynthesis (MIPO). But, there are little comparative data of the outcomes between open plating and MIPO techniques. We compared the outcomes of open plating and MIPO for treatment of acute displaced clavicular shaft fractures. Materials and methods The author performed a retrospective review on a consecutive series of patients with clavicular shaft fracture who underwent open plating or MIPO. Fourteen patients were treated with open plating with interfragmentary screw fixation, and 19 were treated with the MIPO technique without exposing a fracture site itself. A superior plating method was applied to both groups. Patient demographics, clinical outcomes using Constant score and University of California Los Angeles (UCLA) shoulder score, operation time, union rate, complications, and radiographic evaluation were evaluated. Results There were no statistically significant differences in the demographic data, including patient's variables (age, gender, involved side, smoking, alcohol, and diabetic status) and fracture characteristics (trauma mechanism, distribution of fracture type, presence of polytrauma, and time from trauma to surgery) between the two groups. Mean operation time was 87.5 min in open plating and 77.2 min in MIPO ( p = 0.129). The mean time to union was 15.7 weeks in patients who underwent open plating and 16.8 weeks in patients who underwent MIPO ( p = 0.427). Although there was no significant difference, nonunion developed 1 case in MIPO while none was in open plating. Four patients in open plating had skin numbness (none in MIPO, p = 0.024). There was no significant difference in the Constant score and UCLA score of the two surgical methods. Conclusion This study showed that both open plating with interfragmentary screw fixation (Open plating) and minimally invasive plate osteosynthesis (MIPO) are equally effective and safe treatment methods for acute displaced clavicle shaft fracture.

Purpose The aim of this study was to evaluate the feasibility of performing minimally-invasive plate osteosynthesis (MIPO) in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures. Materials and methods We performed nine dissections of specimens that were submitted to tibial MIPO with two posteromedial incisions. One locking compression plate (LCP) of 14 to 16 holes was inserted into the submuscular tunnel in a retrograde manner. Incisions were linked to evaluate the distance between neurovascular structures and the plate. Results During the proximal incision, a blunt dissection between semitendinosus and medial gastrocnemius tendons, as well as their lateral shift, helped to protect the main local neurovascular structures. In its distal portion, the submuscular plate tunnel insertion and its direction to the proximal incision prevented direct contact and possible damage to neurovascular structures. Moreover, we obtained successful results from a patient submitted to this procedure. Conclusion Posteromedial MIPO represents a safe and attractive alternative for tibial fractures, particularly if there are damaged soft tissues in the anterior and medial side, or when access to intramedullary osteosynthesis is blocked.

Background No publication has yet described the interface between the radius and the plate in various positions. Neither clinical examination nor assessment of fracture radiographs provides information about the anatomy of the radius before injury. Purpose We investigated radius anatomy to analyse dorsal and volar plate-to-bone fit for radial shaft fracture management. Methods We examined 20 specimens from human adult cadavers. An 8-hole 3.5-mm titanium locking plate was used at three different positions on the dorsal and the volar side of the bone. The space between the well-positioned plate and the radial shaft was attained for each hole of the plate. Results The average space between the midshaft radial cortex and the plate holes for all positions was 0.69 mm (range: 0.0 mmto 2.38 mm). The greatest mean distance between the plate and the radial cortex was measured at the volar mid-diaphyseal position of the plate with an average of 1.31 mm. Conclusion This incongruence between the radial cortex at the volar diaphysis and the plate should be considered when applying plates to this position of the radius. The results of this cadaver study indicate that radius plate osteosynthesis should preferably be done from the dorsal side.

Treatment for mid-shaft clavicle fractures has recently seen a paradigm shift towards surgical management. The aim of the study was to compare clinical and functional outcome between plate osteosynthesis and conservative line of management in middle-third clavicle fractures.A prospective randomized study was conducted on 69 patients with closed displaced clavicle fractures between May 2014 and May 2016. Patients with medial or lateral third clavicle fractures, polytrauma and compound fractures were excluded from the study. Patients treated with plating were in group A (n = 36) while those treated with arm pouch were in group B (n = 33).The mean age of the patient in group A was 32.4 ± 43 and group B was 31.7 ± 26 years. 48 (69.9%) females were involved in the study. History of fall was the most common mechanism of injury affecting 51 (73.9%) patients. All the patients were type 2 B as per the Robinson classification system. The average operative duration was 78.3 ± 12.4 min. Union was seen at 15.6 ± 0.8 in group A and 22.8 ± 0.4 in group B (p 0.0001). Two (6%) of the patients in group B had non-union. One (2.7%) patient in group A had mal-union. Two (5.5%) patients had plate prominence. One (2.7%) patient had superficial infection. The Constant and Murley scoring at 24 months was 89.42 and 76.24 in group A and group B respectively.Plating for displaced mid-shaft clavicle fractures is can lead to better functional and radiological outcomes with minimal complications as compared to the conservative modality of treatment.

The three currently used methods of treatment: namely open reduction plate osteosynthesis (ORPO), Minimally invasive plate osteosynthesis (MIPO), antegrade intramedullary nailing(IMN) are all reported as satisfactory procedures for treatment of humeral shaft fractures. However none of the published reports have a comparison of superiority of one procedure over the other. We evaluated the clinical, radiological and functional outcome of the three procedures.We studied adult patients with humerus shaft fractures over a period of 2 years from May 2014 to May 2016 in a level 1 trauma center. Forty-four were treated with IMN, 34 treated with ORPO, and 34 with MIPO. The null hypothesis tested in this study is that there is no difference between IMN, ORPO, MIPO with respect to union time, surgical time, complication rate, non-union rate and functional outcome. Functional outcome was studied by comparing the UCLA shoulder and MEP scores in the three groups.112 patients were studied consisting of 83 males and 29 females with mean age of 39 years (range 18-70). IMN group showed early union with mean of 12.73 weeks compared to MIPO (14.45 weeks) and ORPO(13.58 weeks), (p0.05). MIPO had no events of non-union, as compared to ORPO (5 non-unions) and IMN (10 non-unions), (p=0.04). The range of movement at the shoulder with the UCLA score was significantly better with a score of 32.26 in MIPO as compared to 27.54 in IMN and 28.82 in ORPO (p0.05). The difference in MEPS score in the three groups was not significant (p=0.31). IMN required a mean of 117.95 minutes intraoperatively as compared to 131 and 150.58 mins in MIPO, ORPO respectively.MIPO is overall better with respect to non-union, functional outcome and complications rate. The surgical time depends on the surgeons' skill and learning curve. Thus considering the advantages and risks involved in the various procedure and surgical acumen, each case should be individualized to have a good outcome. We advocate that MIPO can be safely used as an alternative in treating these fractures.

Background Recently, minimally invasive plate osteosynthesis (MIPO) has been widely used for the treatment of proximal humeral fractures. However, there is concern about whether the MIPO in comminuted proximal humeral fractures is also comparable to open plating. The purpose of this study was to compare the clinical and radiographic outcomes of open plating and MIPO for acute displaced proximal humeral fractures. Materials and methods In this prospective, randomized controlled study, 107 patients who had an acute proximal humeral fracture were randomized to either the open plating or MIPO techniques. Forty-five patients treated with open plating and 45 with the MIPO technique who were followed up at least 1 year were evaluated. Shoulder functional assessment, operating time, several radiographic parameters, and complications were evaluated at final follow-up. Results The mean follow-up period was 15.0 months in the open plating and 14.3 months in the MIPO technique. There were no statistically significant differences in functional assessment scores and radiographic parameters between the two groups. High complications rates were found in 4-part fracture in both surgical methods The average operation time in the MIPO group were significantly lower compared to the open plating group ( p Conclusion This study showed MIPO in proximal humerus fractures had similar clinical and radiographic outcomes compared to the open plating. However, the MIPO technique in proximal humerus fracture provided significantly shorter operation time than the open plating.

Summary With the introduction of Locking Compression Plates (LCP), Minimally Invasive Plate Osteosynthesis (MIPO) has become widely used. The plates act as internal fixators in a bridging manner, thus resulting in secondary bone healing. We retrospectively evaluated the healing pattern and the clinical evolution of diaphyseal and distal tibial shaft fractures over two and a half years in 32 patients (6 females, 26 males). Fractures were classified according to AO classification and included all 42A-C, 43A-B and 43C1-2 types. For open fractures, Gustillo Anderson classification was used. Plates consisted of the 4.5 mm LCP and 3.5 mm LCP-Pilon form plate. Clinical and radiological assessment was performed at 6 weeks, and at 3, 6, 9, and 12 months. Two patients were lost to follow-up. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and posterior–anterior X-ray, and full, painless weight bearing. Ten patients at 3 months, 23 at 6 months, and 27 at 9 months met the criteria for a healed fracture. Plate bending was observed in one patient and called for re-operation at 5 months. Two patients required re-operation at 13 months secondary to pseudoarthrosis. Though MIPO seems more advantageous for soft tissue and bone biology, prolonged healing was observed in simple fracture patterns when a bridging plate technique was used.

Aim The aim of this study was to compare the clinical and radiographic outcomes between two different plating methods (superior vs. anteroinferior) in minimally invasive plate osteosynthesis (MIPO) for acute displaced clavicular shaft fractures. Materials and methods A prospective, randomized controlled trial was performed in a single centre. Nineteen patients were treated with superior plating and 18 with anteroinferior plating using the MIPO technique. A 3.5-mm locking reconstruction plate was bent preoperatively and applied to either the anteroinferior or superior aspect of the clavicle through two separate incisions. The operating time, time to union, the proportional length difference, complications, and functional outcome of the shoulder joint were evaluated using the Constant score and the University of California Los Angeles (UCLA) score. Results There was no statistically significant difference in the Constant score and UCLA score. The mean time to union was 16.8 weeks for superior plating and 17.1 weeks for anteroinferior plating (p=0.866). The average operation time was 77.2min in superior plating and 79.4min in anteroinferior plating (p=0.491). One patient in the superior plating group showed plate failure. Despite no significant difference, one patient had nonunion in the superior plating group (p>0.999). Conclusions From a clinical perspective, although MIPO with anteroinferior plating provides better outcomes especially in complications without statistically significant difference, both plating methods provided satisfactory clinical and radiographic outcomes. Level of evidence Level I, a single-centre, prospective, randomized controlled trial.

The dynamic locking screw (DLS) in association with minimally invasive plate osteosynthesis (MIPO) in a bridging construct for simple metadiaphyseal long bone fractures enables modulation of the rigidity of the system and facilitates the development of early and triplanar bone callus. Twenty patients affected by distal tibial fracture were treated with MIPO bridging technique and DLS at the proximal side of the fracture. Time of consolidation, quality of the reduction, complications and American Orthopaedic Foot and Ankle Society (AOFAS) score were monitored and the results compared with those from a control group treated with only standard screws on both fracture sides. Student t-test for independent samples was used for the comparison of means between the two groups. Chi-square test was used for the comparison of proportions. A multiple logistic regression model was constructed to assess the possible confounding effects. Performance was considered significant for p0.05. The mean healing time was 17.6 ± 2.8 weeks in the group treated with standard screws and 13.5 ± 1.8 weeks in the group treated with DLS (t=5.5, p0.0001). The DLS was associated with early healing and triplanar bone callus.

Minimally invasive plate osteosynthesis (MIPO) using a locking plate has been widely used for distal femur fractures in the elderly with osteoporosis and yielded favourable results. However, implant failure and subsequent periplate fracture have still occurred owing to the controversy of concepts regarding locked plating. The treatment after failed MIPO in elderly patients is very challenging and has been not yet addressed definitely in the literature, although several options can be considered. We report the successful outcomes of two cases treated with overlapping intramedullary (IM) nailing for implant failure and periplate fracture after MIPO for osteoporotic distal femur fracture, along with simple tips of distal interlocking of IM nail.

In order to gain a better understanding of the healing processes after plate fixation and indirect reduction, Baumgaertel designed a reproducible fracture model for the sheep femur in 1992 so that the differences between anatomical (rigid) and biological (bridging) fixation could be investigated. It was demonstrated that indirect reduction and bridge plating was superior to direct fragment reduction and anatomical fixation in respect to radiology, biomechanics and microangiography. In this study, it was shown that bony bridging of the fracture gap and mineralization of callus occurred faster and more efficiently after indirect than after direct and anatomical reduction. Bone healing was identified as beginning in the 2.–3 week after indirect and only in the sixth week after direct reduction. The increased breaking strength of the indirectly reduced femora at 8 weeks can be attributed to this process. In addition, the consequences of applying the PC-Fix for biological plating were investigated. The values for bone healing were improved by applying a plate with only point contact to the bone, thus conserving the periosteal blood supply.

In a prospective study conducted between 1992 and 1995, displaced Müller type C2-C3 intraarticular fractures of the distal femur were treated using an indirect plate fixation technique and a lateral parapatellar arthrotomy for the direct reduction of the condylar block. There were 6 closed, and 2 open fractures (1 grade II and 1 grade IIIB). Following reconstruction of the articular block, the block was indirectly reduced and fixed to the shaft by a plate inserted by the retrograde method beneath the vastus lateralis. Transcutaneous/transmuscular screws were used to fix the plate to the shaft. Time to bone healing was 12 weeks (median range 8-17 weeks) after surgery without needing primary or secondary bone grafts. There were no infections or refractures. Except for one case which required a corrective osteotomy for 10 degrees of varus malalignment, there were no revisions. According to the Neer score, there were 6 excellent or satisfactory results, 2 unsatisfactory results, and no failures. At follow-up, there were 2 varus-valgus deformities greater than 5 degrees, 2 leg length discrepancies greater than 10 mm, and 2 rotational deformities of 15 degrees. The treatment results for complex supracondylar/intracondylar fractures of the distal femur obtained with this technique compare favourably with other reported series using different techniques without the added morbidity associated with autogenous bone grafting. However, the surgical technique is demanding and special care must be taken to ensure correct axial alignment.

Summary The purpose of this study was to evaluate the basket plate in the treatment of comminuted fractures of the distal pole of the patella (patellar apex fracture). The basket plate was designed by Smiljanic Branimir M.D., Clinical Professor of Surgery, at the Department of Surgery, The University Hospital Sestre milosrdnice, Zagreb, Croatia. In the period from 1988 to 2003, more than 100 patients with comminuted patellar apex fractures had been treated with basket plate osteosynthesis in the Department of Surgery. Only 51 patients were subsequently available for knee examination. For evaluation of the knee, we used a modified Cinncinati knee rating system, using a manual dynamometer in the evaluation of the knee extension. The results were excellent in 30 patients, good in 16 and satisfactory in 5 patients; no poor results were observed. The stability of the osteosynthesis by basket plate allows osseous consolidation if the fracture and permits loading the leg with full body weight early in the postoperative period.

The development of the Locking Compression Plate (LCP) reflects the multilateral collaboration of clinicians, researchers, developers and industry. In retrospect, combining two completely different anchorage technologies into one implant is logical and the practical solution is simple. The clinical instructions for the new implant, which severely limited the constructive scope, proved to be critical for the project. Unlike an independent new development, compatibility with existing surgical techniques, instruments and implants had to be maintained. Industrial implementation of the LCP is only possible with the use of state-of-the-art production centres with up to five computer-controlled axes. The unlimited possibility of using the LCP as a compression plate, an internal fixator or in a specific combination allows ideal plate anchorage that is adapted to the bone. Combined with minimally invasive implant technology (MIPO), the indication spectrum of plate osteosynthesis can be expanded in a meaningful manner.

We reviewed 49 patients following plate osteosynthesis of humeral shaft fractures. There were no complications as a result of surgery. Union occurred in 47 patients (96%) at a mean of 9 weeks. Two patients required secondary procedures to achieve union. All patients had full range of motion in the elbow and shoulder joints following union. In the light of the popularisation of intramedullary nailing techniques in the last decade, with recognised complications of iatrogenic radial nerve injury, inadequate rotational stabilisation, non-union and shoulder impingement, we advocate plating of humeral shaft fractures as the surgical treatment of choice.

When applying minimally invasive techniques (MIO, Minimally Invasive Osteosynthesis) to the fixation of the distal femur, the surgeon has access to a limited number of anatomical landmarks: namely the articular surface of the distal femur and a small portion of the distal lateral femoral cortex. A detailed knowledge of the local anatomy facilitates the techniques and prevents complications. Using Kirschner wires placed set positions in the distal femur, we analyzed the measurements obtained from the 3D reconstructed helical CT scans of 33 embalmed femora and we report on the anatomy of the distal femur as it relates to supracondylar fracture fixation.