LCP as MIPPO vs LCP as external fixator (supracutanoeus mode) in open grade 1 fractures of distal tibia: A comparison study from hills of northern India

Introduction: Fracture to tibia is one of the most common fracture encountered in a career of an orthopaedic surgeon. Because of the often high energy involved and the precarious soft tissue cover that surrounds the distal tibia, such fractures command watchful attention to the soft tissue cover for timing and method of surgical fixation. In recent years, the concept of biological osteosynthesis has gained a reputation in fracture treatment. And in order to maintain biology of the fracture and to expedite the healing process many institutions and surgeons are using minimal invasive methods for distal tibial fixation. However till date no comparison is being made between the use of MIPPO and supracutaneous plating for distal tibial fractures. We are the first one to show our experience and results with these two biological methods in 40 cases of grade 1 Gustilo and Anderson fractures of distal tibia in a tertiary care centre situated in hilly terrain of northern India.

Methods: The present study was carried out in the department of Orthopaedics from 1.01.2019 to 1.06.2021. 40 patients in age >18 yrs who had Gustilo and Anderson type 1 fracture of distal Tibia of both sexes were enrolled in this prospective study done at Pt. Jawahar Lal Nehru Govt medical college Chamba, Himachal Pradesh. They were randomized into 2 groups of 20 each according to the day of admission. In one group (MIPPO) mippo was done in gustilo and Anderson grade 1 distal tibial fractures and in antoher group Supracutaneous plating was done (SCP). In each determined follow up at and after 6 weeks, clinical assessment of range of motion, radiological evaluation for progression of fracture healing and complications were documented. The functional outcome of the ankle was assessed with the help of AOFAS (American Orthopedic Foot and Ankle Society Ankle Score) and Teeny and Wiss criteria (symptoms and functional evaluation of ankle) at 12 months. Complications like surgical site infection, deep infection, delayed union, non-union and ankle stiffness were documented.

Results: We found no difference in the time to union in weeks in the two groups (SCP-21 months, MIPPO 20 months). However, operating time was significantly longer in the MIPPO group (97.9 vs 81.2 minutes, p<0.001, respectively). Patients who had SCP had Less pain and a better function, alignment and total AOFAS score than the MIPPO group. These results were statistically significant. There were more wound problems both superficial and deep infections in the MIPPO group. Total duration of stay was significantly shorter in SCP group {10 vs 22 days (inclusive of implant removal). Radiological outcome using Teeny Wiss radiological score was almost similar in both the groups. AOFAS Score including pain and function score was better in SCP group as compared to MIPPO group.

Conclusion: The high percentage of unions, the low rate of complications, comparatively less surgical time, easy implant removal and better functional scores suggest that using LCP in supracutanoeus mode can be a reasonable alternative to MIPPO for treating distal tibia fractures. Future prospective randomized studies may be able to clarify these issues.