Minimally invasive Percutaneous Plate Osteosynthesis for Ankle Fractures: a Prospective Observational Cohort Study

SLR- February 2014- Eric Muhm

Reference: Pires RE, Mauffrey C, de Andrade MA, Figueiredo LB, Giordano V, Belloti JC, Dos Reis FB. Minimally Invasive Percutaneous Plate Osteosynthesis for Ankle Fractures: A Prospective Observational Cohort Study. Eur J Orthop SurgTraumatol. 2013.

 

Reviewed by: Eric Muhm, DPM
Residency Program: Detroit Medical Center, Detroit, MI

Podiatric Relevance: Open reduction with internal fixation(ORIF) has become the gold standard for the treatment of displaced fractures of the lateral malleolus. However, wound complication rates with this approach have been reported to be as high as 18 percent. The risk of post-operative wound complications is even greater in certain patient populations including those patients who have a history of diabetes mellitus, have a history of PVD, and also those patients who use tobacco products. Recent studies have advocated for the use of a minimally invasive percutaneous approach in these at-risk patients. Such an approach would provide the podiatric surgeon with an alternative treatment method for those patients who are determined to be at high risk for such complications.
 

Methods: In this case series, 20 patients (18 years or older) with Danis-Weber type B ankle fractures were treated utilizing the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique from October 2009 to February 2010. Exclusion criteria was as follows: open fractures, Danis-Weber type A and type C fractures, and ankle fractures associated with other injuries. Quality of intra-operative reduction was evaluated radiographically by assessing Shenton's line, talo-crural angle, dime’s sign, and lateral malleolar rotational control. The data, which was prospectively collected, included duration of surgery, patient comorbidities, mechanism of injury, fluoroscopy time, fracture classification, and trauma surgery interval. Patients were required to follow-up for a minimum of one year at intervals of six weeks, eight weeks, three months, six months, and at 12 months. Data was collected during these follow-up intervals in order to assess for post-operative complications. This set of data included presence of a deep vein thrombosis, infection, painful scar formation, prominent implant, CRPS, as well as functional outcomes using the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale. A fracture was considered healed when at least three cortices showed no fracture line.

Results: In this study, the MIPPO technique was utilized to treat 20 patients (16 F, 4 M) with a Danis-Weber type B ankle fracture. The mean follow-up time in this case series was 16.5 months. Average patient age was 53.3 years with a range of 19 to 80 yrs. Average time from injury to surgery was 4.4 days. Average surgery time was 32.8 minutes from incision to closure. Only two patients (10 percent) in this study presented with comorbidities (one hx of gout, one diabetic). Average fracture healing time was eight weeks. The patients AOFAS score after a 12 month follow-up was considered satisfactory with an average of 88 and a range of 72 to 100. Two patients presented with post-operative complications. One patient with skin necrosis which required hardware removal and one patient with a mal-union secondary to a poor intra-operative reduction. 

Conclusions: This case series supports the use of the MIPPO technique as an alternative approach for the treatment of Danis-Weber type B ankle fractures. Although this technique is not complication free, only one patient in the study suffered wound complications secondary to surgery. As mentioned in the beginning of this review, certain patient populations (diabetics, smokers, patients with PVD) are at high risk for post-operative wound complications. Unfortunately this study did not provide much insight on these specific patients as only one patient included in this study fit into one of those categories. So in conclusion, although the minimally invasive precutaneous approach is a promising technique for the fixation of ankle fractures in at-risk patients, more research needs to be done looking specifically at these high risk groups.