Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report

Abstract

Purpose: The aims of this anatomical study were to evaluate the feasibility of minimally invasive plate osteosynthesis (MIPO) using a posterolateral approach in distal tibial fractures and to study the relationship between neurovascular structures and the plate.

Methods: Two separate incisions, one proximal and one distal, were made on the posterolateral aspect of ten cadaveric legs in the prone position. A 14-hole contralateral anterolateral distal tibial locking plate was inserted into the submuscular tunnel using a posterolateral approach, and one screw was fixed on each side of the proximal and distal tibia. The MIPO tunnel was then explored to identify the relationship between neurovascular bundles and plate.

Results: For the proximal incision, retraction of the flexor hallucis longus and the tibialis posterior muscles medially was very important because it could protect the posterior tibial artery and the tibial nerve during plating. The sural nerve and lesser saphenous vein were easily identified and retracted in the superficial layer of the distal incision. In addition, we achieved satisfactory outcomes after using this MIPO technique in one patient.

Conclusion: Based on the results of our study, it seems that using the MIPO technique through a posterolateral approach should be a reasonable and safe treatment option for distal tibial fractures, especially when the anterior soft tissue is compromised. However, studies with a higher level of evidence should be done in more patients to confirm the clinical safety of using this technique.

Fig. 1

a Distal and proximal skin incisions (red lines). b Cross-section of the distal tibia showing the interval plane between the peroneal muscles and the flexor hallucis longus (FHL). c Cross-section of the mid tibia showing the interval plane between the peroneal muscles and the FHL

Fig. 2

a Precontouring the anterolateral distal tibial locking plate to the shape of the posterolateral aspect of the tibia (plastic bone) in AP view. b Precontouring the anterolateral distal tibial locking plate to the shape of the posterolateral aspect of the tibia (plastic bone) in lateral view

Fig. 3

a Insertion of the plate from the distal to the proximal incisions. b Opening the tunnel to explore structures at risk during proximal incision [posterior tibial artery (PTA) and tibial nerve (TN); white arrow). c Measurement of distances between the neurovascular bundle (black arrow) and the plate (asterisk) at the proximal incision

Fig. 4

a Tibial nerve (TN) and posterior tibial artery (PTA) (white arrow), just medial to the flexor hallucis longus (FHL) (black arrow) and the tibialis posterior muscle (TP) (asterisk). b To decrease the risk of neurovascular injury, the dissection was initially made between the FHL and the posterior border of the fibula. After that, the FHL (black arrow) and TP (asterisk) were retracted medially to protect the neuromuscular bundle (white arrow). c The plate (asterisk) was very close to the PTA and TN (white arrow), whereas there was no protection from the FHL and TP (black arrow)

Fig. 5

a A 27-year-old polytraumatised male patient with a Gustilo type IIIB open comminuted fracture of the left distal tibia [Arbeitsgemeinschaft für Osteosynthesefragen (AO 43–C2)]. b Initial debridement and stabilisation with a spanned external fixator across the ankle joint. c Colistin beads (white arrow) were placed at the fracture gap, then the exposed medial distal tibia was covered by the sural flap (black arrow). d Two separate proximal and distal incisions (red lines). e Insertion of the locking plate following the track of the minimally invasive plate osteosynthesis (MIPO) tunnel. f Immediate postoperative plain radiographs showing good alignment of the distal tibial fracture. g Radiographs showing complete healing of the distal tibial fracture. h The patient had a good range of motion of the left ankle