MINIMALLY INVASIVE SURGERY FOR CLOSED LOWER LIMB FRACTURES: PAST AND PRESENT EXPERIENCES WITH CONVENTIONAL AND UPDATED DEVICES IN 90 CASES.

Abstract

Fractures of distal femur and tibia treated with Open Reduction and Internal Fixation (O.R.I.F.) are frequently complicated in the postoperative period. Minimal Invasive Plate Osteosynthesis (MIPO) is developing for subcutaneous plating. The purpose of this study is to demonstrate the improvement in dropping the risks of complications following internal fixation of closed fractures of the lower limb using MIPO in comparison with conventional O.R.I.F. procedure. From January 1998 to May 1999 we collected 32 cases of lower limb fractures (10 distal femur, 15 pilon, 7 distal tibia) treated with O.R.I.F procedure (Group I). The mean age was 47.6 years (range 23–76). From June 1999 we started to perform MIPO in closed fractures of lower limb with conventional devices (36 cases). From March 2001 we performed part of our minimal invasive surgery (54 cases) with new devices with angular stability (Less Invasive Stabilization System, Synthes) that offer more tools for subcutaneous osteosynthesis and more mechanical stability of the implants. Our 90 cases formed Group II. The mean age was 53.2 years (range 21–80). The mean follow up was 18 months. We used bone grafts in only 1 case of severe pilon fracture. In Group I we got 2 infections in pilon fractures, 3 delayed union in distal tibial fractures, 1 non-union in distal femoral fracture, 1 varus deformity in distal femoral fracture and 2 DVT. In Group II we had no infection, no delayed or non-union (a mean consolidation time of 8–10 weeks for pilon fractures, 6 weeks for distal tibia fractures, 10–12 for distal femoral and proximal tibia ones). 2 cases of varus deformity in 1 pilon fractures (1 MIPO); 1 DVT in distal tibial fracture; 2 cases of varus deformity of distal femoral fracture (1 DCS). Conventional O.R.I.F. surgery showed some limits: wide exposure, damage to vascular supply of soft tissues and bone, blood loss, high risk of infections, not indicated in polytrauma patient: international literature reported high rate of postoperative complications. The findings of this study justify the effort to follow this procedure also because the new devices available improved mechanical stability and facilitated this technique In conclusion, minimal invasive surgery is a demanding technique with undoubted advantages: it reduces surgical exposures and risk of infection; it respects the biology of callus and soft tissues, it reduces the necessity of bone graft and is particularly indicated in polytrauma patients.