INTRODUCTION: Fractures of the distal tibia have been a challenging situation. Stable fractures with minimal shortening can be treated conservatively, but requires prolonged immobilisation. It has also been associated with malunion, shortening of affected 1, 2limb, restriction of range of motion and early osteoarthritis. External xation can be a useful option in open fractures with soft tissue injury, but can lead to pin-track infections, septic 3 arthritis, mal-alignment and delayed union. Soft-tissue management has been seen to play a vital role in the 4management alongside the bony reconstruction . Internal xation usually failed due to infection, inadequate skin coverage and avascular necrosis of the skin leading to 5sloughing. In a study of 84 patients by Ruedi and Allgower , that established the open reduction and internal xation with screws and plate as the standard, the authors with a nine year follow up reported 74% good functional results. The principles of treatment included 1. Re-establishment of the bular length 2. Re-construction of the lower articular surface of tibia 3. Placement of metaphyseal bone graft; and 4. Stabilization of the medial aspect of tibia using a plate 6In a series of 26 patients, Kellam and Waddell divided them into 2 groups based on fracture pattern. Type A fractures with twisting injuries with little comminution, whereas Type B fractures were more severe injuries, with a crush component. Better results were obtained in Type A fractures (84%) than B (53%). Crucial factors besides fracture type were the length of 7immobilization and quality of reduction. Bourne et al , in a retrospective clinical review of 42 patients treated with open reduction and internal xation demonstrated the importance of using a logical classication system in describing the outcome of fractures of the distal tibia. The results of this study have clearly demonstrated that Types I and II (Ruedi and Allgower) are amenable to open reduction and stable internal xation with an 80% success rate. The Type III fractures present a much more difcult problem; a satisfactory outcome was present only in 6 of the 19 patients (32%) in this study. 9Dillin and Slabaugh , in a series reported disastrous results when inadequate and unstable xation was used to treat the FUNCTIONAL OUTCOME OF DISTAL TIBIA FRACTURES TREATED WITH LOCKING COMPRESSION PLATES USING MIPPO TECHNIQUE Original Research Paper Amit Yadav Senior Resident, H.b.t. Medical College And Dr. R.n. Cooper Hospital, Mumbai; Address: Room No.407,rmo Quarters,dr.r.n. Cooper Hospital,vile Parle(west),mumbai, Maharashtra- 400056 X 9GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS Orthopaedics VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Ali Saify Post-graduation Student, H.b.t. Medical College And Dr. R.n. Cooper Hospital, Mumbai.;address: M31,khatiwala Tank,angan Apt.,at No- 203,indore,madhya Pradesh-452014 Dr. Ganesh Yeotiwad* Assistant Professor, H.b.t. Medical College And Dr. R.n.cooper Hospital, Mumbai;address:at No.301,aadhikari Niwas,cooper Hospital Campus,vile Parle(west),mumbai, Maharashtra-400056 * Corresponding Author Sagar G. Daliya Post-graduation Student, H.b.t. Medical College And Dr. R.n. Cooper Hospital, Mumbai;address: Room No.202, Rmo Quarters,dr.r.n. Cooper Hospital,vile Parle(west),mumbai, Maharashtra-400056 Pagadala Manikanta Babu Post-graduation Student, H.b.t. Medical College And Dr. R.n. Cooper Hospital, Mumbai.;address: Room No.202, Rmo Quarters,dr.r.n. Cooper Hospital,vile Parle(west),mumbai, Maharashtra-400056 BACKGROUND: The limited soft tissue, subcutaneous location of large portion of tibia and precarious blood supply renders the treatment of distal tibial fracture very challenging. Conventional osteosynthesis is not suitable because distal tibia is subcutaneous bone with poor vascularity. Closed Reduction and MIPPO with locking compression plate (LCP) has emerged as an alternative treatment option because it respects biology of distal tibia, maintains fracture haematoma and provides biomechanically stable construct, early mobilization, less complications and relatively higher rates of union. METHODS: 30 patients with distal tibia fracture with or without intra articular extension were treated with Closed Reduction and MIPPO with locking compression plate (LCP) Closed Reduction and. The patients were prospectively followed up for the duration of 12 months. RESULTS: There were 30 patients in the study including 22males and 8 females in the age group of 23 to 62 years (average 42years). The mean follow up period of our patients varied ranging from 6 months to 12 months. All fractures united at an average of 16 weeks (range- 12 to 20 weeks). In our study rate of supercial infection was 16.7% (5 patients), and ankle stiffness 6.7% (2 patients) .There were no cases of deep infection, delayed union, malunion or non union. CONCLUSION: MIPPO with LCP is a reliable and effective method of treatment for the distal tibia fractures with or without intra articular extension, preserving most of the osseous vascularity and fracture haematoma and thus providing for a more biological repair. The use of indirect reduction technique and small incision is technically demanding as it is effective, minimally invasive, safe, optimises the operation time, reduces the incidence of infection, allows restoration of limb alignment and provides good clinical and radiological results with low complications and high union rates. ABSTRACT KEYWORDS : Distal Tibia Fracture, Mippo, Functional Outcome, Lcp 10 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS distal tibia fractures. They had 36% rate of skin sloughing and a 55% infection rate16. Follow up evaluations of 34 distal tibia 10fractures by Helfet et al , showed that results of operative treatment are dependent on the severity of the initial injury, the 12quality and stability of the reduction. Hazarika et al , in a series of 20 patient of distal tibia fracture treated using locking compression plates through MIPPO technique. This provided 1387.5% of good to excellent results. Ozakaya et al , in a retrospective review of 22 patients with distal third tibia fractures were treated with titanium locking compression plates using minimally invasive technique good biological xation of distal tibia. A total of 81% of good to excellent outcome was assessed using American Orthopaedic Foot and 13Ankle Society Score . Locking plates (LPs) have the biomechanical properties of internal and external xators, with superior holding power because of xed angular stability through the head of locking screws, independent of friction 14t . With the increasing prevalence of high energy injuries and the accompanying soft tissue damage, more recent treatment protocols have focused on maintaining a healthy soft tissue envelope while reducing the articular surface by indirect means using minimally invasive techniques. Minimally Invasive Percutaneous Osteosynthesis aims at minimal periosteal dissections and disruption of hematoma, stable xation and early mobilization, decreased post- operative complications and higher rates of union. More importantly it helps preserve the fragile soft tissue envelop 19,20and avoids stripping of the precious periosteum. METHODS: The present study was conducted in the inpatient and outpatient department of orthopaedic surgery, H.B.T. Medical College & Dr. R. N. Cooper Municipal General Hospital, Mumbai during the period of September 2017 to September 2019. We involved 30 patients of distal tibia fractures, after satisfying the inclusion and exclusion criteria. Ethical committee clearance was obtained prior to the study Patients were given information sheet and details of the study were explained. After obtaining written informed consent, patients were enrolled into study. Inclusion Criteria were Age more than 18 years, both males and females with Distal tibia fractures both intra-articular and extra-articular. Exclusion criteria included patients less than 18 years of age, patients unt for surgery, Gustilo Anderson Type-III open fractures. Plain Radiographs were taken, antero-posterior view and lateral view of full length tibia and bula along with ankle mortise view of the affected side was obtained. The fractures were classied using AO/OTA classication system. The patient was posted for surgery, once anaesthesia tness was obtained. The surgical procedure of xation with LCP using MIPPO technique was carried out on a fracture table with Image Intensier. Tourniquet was applied routinely. In patients with distal bula fracture, it was xed rst by open reduction using 3.5mm reconstruction plate/distal bula pre-contoured locking plate. Patients were followed up and evaluated in detail post operatively both clinically and radiologically at 1 week, 4 week, 2 months, 4 months, 6 months,9 months and 1 year. At every follow up clinical examination was done to assess status of the surgical wound, pain, swelling, tenderness, range of motion, stability of the fracture and clinical union RESULTS: There were 30 patients in the study including 22males and 8 females in the age group of 23 to 62 years with mean age of 42 years(Table 1). Table 1: Age group distribution. The fractures were classied according to AO–OTA classication in to various types. Out of 30 cases, 6(20%) were Type A1, 12(40%) Type A2, 11(36.6%) Type A3 and 1(3.3%)Type B1. 23(76.7%) of patients sustained injury following road trafc accidents and 7(23.3%) patients sustained injury due to fall. 26 (86.6%) cases were closed fractures and 4 (13.3%) cases were open fractures. Classication of the 4 cases of open fractures was done based on Gustillo Anderson classication of open fractures, 3(75%) were type 1 compound, 1(25%) were type 2 compound. 23(76.7%) of patients sustained injury following road trafc accidents and 7(23.3%) patients sustained injury due to fall. Follow-up period of our patients varied ranging from 6 months to 24 months. The mean time to union was 16 weeks, (range– 12 weeks to 20 weeks). Out of 30 cases, 23(76.7%) had no complications, 2(6.7%) developed ankle stiffness, 5(16.7%) developed supercial skin infection(Table 2). Table 2: Post op complications. Five supercial wound infections were treated with oral antibiotics and regular dressing. All patients were kept nil weight bearing till radiological signs of union was seen. Functional outcome was evaluated as per clinical scoring by Teeny and Wiss criteria. 8(26.7%) had excellent outcome, 17(56.7%) good Outcome, 3(10%) fair outcome and 2(6.7%) had poor outcome(Table 3). Table 3: Functional outcome. In our study there was a statistical signicance between age and functional outcome with cases in age group 23 to 30 years having more excellent outcome compared to patients more than 50 years.(Table 4) Table 4 : Association between Age and Functional Outcome In our study there was a statistical signicance between post operative complication and time of union, with longer duration of union in cases with complication like infection as shown in the graph. The study showed statistical signicance between gender and time of union with early union rates in male VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra Age group Frequency Percent 23 to 30 years 5 16.7 31 to 40 years 12 40.0 41 to 50 years 6 20.0 51 to 60 years 5 16.7 more than 60 years 2 6.7 Total 30 100.0 POST OP COMPLICATIONS Frequency Percent Absent 23 76.7 Ankle Stiffness 2 6.7 Supercial Skin Infection 5 16.7 Total 30 100.0 Functional Outcome Frequency Percent Excellent 8 26.7 Fair 3 10.0 Good 17 56.7 Poor 2 6.7 Total 30 100.0 Functional Outcome Total Excellent Fair Good Poor Age group 23 to 30 years Count 4 0 1 0 5 % 50.0% 0.0% 5.9% 0.0% 16.7% 31 to 40 years Count 1 0 10 1 12 % 12.5% 0.0% 58.8% 50.0% 40.0% 41 to 50 years Count 2 2 2 0 6 % 25.0% 66.7% 11.8% 0.0% 20.0% 51 to 60 years Count 1 0 3 1 5 % 12.5% 0.0% 17.6% 50.0% 16.7% more than 60 years Count 0 1 1 0 2 % 0.0% 33.3% 5.9% 0.0% 6.7% Total Count 8 3 17 2 30 % 100.0% 100.0% 100.0% 100.0% 100.0% patients compared to female patients. Also functional outcome was better in male patients. No statistical signicance was found between mode of injury and time of union. DISCUSSION: Fractures of distal tibia are among the most difcult fractures to treat effectively. The status of the soft tissues, the degree of comminution sustained at the time of injury affect the long term clinical results. Treatment of these fractures with conventional plates by open reduction techniques, intra medullary nailing resulted in high rates of complication. With the development of technique of MIPPO with LCP which preserve extraosseous blood supply, respect osteogeinic fracture haematoma, biologically friendly and stable xation method is available for distal tibial fracture. 15Cory Collinge et al observed 100% high energy fractures in his study. However, our present study correlates with the study 18conducted by Neeraj Mahajan who attributed 65% of such injuries to be high energy injuries. In our study, 20% were Type 43A1 fractures, 40% Type A2, 36.6% Type A3 and 3.3% Type B1 22which was comparable to study by Supe AC . The average surgical time was 53 minutes. It is comparable with the 17average of 97.9minutes taken by J.J. Guo et al in their study. The average time for fracture union in various studies conducted using various methods was 16-28 weeks. In study 19by GI et al showed in their study that average time for union was 20 weeks. Our study had an average time of fracture union of 16 weeks which is comparable to study by Muzaffar N 21et al. in which it was 16.8 weeks. CONCLUSION: MIPPO with LCP is a reliable and effective method of treatment for the distal tibia fractures with or without intra articular extension, preserving most of the osseous vascularity and fracture hematoma and thus providing for a more biological repair. The use of indirect reduction technique and small incision is technically demanding as it is effective, minimally invasive, safe, optimises the operation time, reduces the incidence of infection, allows restoration of limb alignment and provides good clinical and radiological results with low complications and high union rates. REFERENCES: 1. Othman M, Strzelczyk P. Results of conservative treatment of “pilon” fractures. Ortop Traumatol Rehabil. 2003;5:787–94. 2. Digby JM, Holloway GM, Webb JK. A study of function after tibial cast bracing. Injury. 1983;14:432–9. 3. Anglen JO. Early outcome of hybrid external fixation for fracture of the distal tibia. J Orthop Trauma. 1999;13:92–7. 4. McFerran MA, Smith SW, Boulas HJ, Schwartz HS. Complicationsencountered in the treatment of pilon fractures. J Orthop Trauma. 1992;6:195–200. 5. Ruedi TP, Allgower M. The operative treatment of intra articular fractures of the lower end of tibia. Clin Orthop 1979; 138: 105-110. 6. Kellam J, Waddell JP. Fractures of the distal tibial metaphysic with intra-articular extension - the distal tibial explosion fracture. J Trauma 1979; 19: 593-601. 7. Bourne R, Rorabeck C, Macnab J. Intra-articular fractures of the distal tibia: The pilon fracture. J Trauma 1983; 23: 591-596. 8. Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg Am. 1986; 68:543-551. 9. Dillin L, Slabaugh P. Delayed wound healing, infection, and non union following open reduction and internal fixation of tibial plafond fractures. J Trauma 1986; 26: 1116-1119. 10. Helfet DL, Koval K, Pappas J, Sanders RW, Dipasquale T. Intra articular "pilon" fracture of the tibia. Clin Orthop 1994; 298: 221-228. 11. Im GI, Tae SK. Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. J Trauma. 2005 Nov; 59(5):1219-23; discussion 1223. 12. Hazarika S, Chakravarthy J, Cooper J. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia – Injury.2006 Sep;37(9):877-87.Epub 2006 Aug 8. 13. Ozakaya U, Parmaksizoglu AS, Gul M, Sokuou S, Kabukcuoglu Y. Minimally invasive treatment of distal tibial fractures with locking and non locking plates. Foot Ankle Int .2009 Dec; 30(12):1161-7 14. Cory Collinge, MD, Mark Kuper , DO, Kirk Larson , RNFA, and Robert Protzman, MD. Minimally Invasive Plating of High-Energy Metaphyseal Distal Tibial Fractures. J Orthop Trauma 2007; 21:355-361. 15. Andrew Grose, Michael. J. Garden. Open reduction and internal fixation of tibial pilon fractures using a lateral approach. J. Orhop Trauma 2007; 21:530-537. 16. Andrew Grose, Michael. J. Garden. Open reduction and internal fixation of tibial pilon fractures using a lateral approach. J. Orhop Trauma 2007; 21:530-537. 17. Guo JJ, Tang N, Yang HL, Tang TS. A prospective, randomized trial comparing closed inramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br.2010 Jul; 92(7): 984-8 18. Neeraj Mahajan, Minimally invasive techniques in distal tibia fractures, J K Science, Vol. 10 No. 2, April-June 2008 19. D.J Redfern, S.U Syed, S.J.M Davies, Fractures of the distal tibia: minimally invasive plate osteosynthesis, Injury, Volume 35, Issue 6, June 2004, Pages 615-620 20. Int Orthop. 2004 Jun;28(3):159-62. Epub 2004 Feb 14.Percutaneous plating of distal tibial fractures.-Maffulli N, Toms AD, McMurtie A, Oliva F. 21. Muzaffar N, Bhat R, Yasin M. Complications of Minimally Invasive Percutaneous Plating for Distal Tibial Fractures. Trauma Monthly. 2016;21(3):e22131. doi:10.5812/traumamon.22131. 22. Supe AC, Kinge KV, Badole CM, Wandile KN, Patond KR. Minimally invasive percutaneous plate osteosynthesis in distal tibial fracture: A series of 32 cases. International Journal of Orthopaedics. 2016;2(1):06-9. X 11GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra