1 Alzahra Hospital, Isfahan University of Medical Science, Isfahan, Iran

2 Isfahan University of Medical Sciences, Isfahan, Iran

3 Azad Islamic University, Najaf Abad branch, Isfahan, Iran


Background: Comminuted fractures happen frequently due to traumas. Fixation without opening the fracture site,
known as minimally invasive plate osteosynthesis (MIPO), has recently become prevalent. This study has been
designed to assess the outcomes of this treatment for tibial and femoral comminuted fractures.
Methods: A total of 60 patients with comminuted femoral or tibial fractures were operated with MIPO method in this
cross-sectional study at Alzahra university hospital in 2015. Eleven patients were excluded due to lack of adequate
follow-ups. Patients’data including union time; infection in the fractured site; hip and knee range of motion; and any
malunion or deformities like limb length discrepancy were collected after the surgery in every session.
Results: Among 32 femoral and 17 tibial fractures, union was completed in48 patients, while only one patient with
femoral fracture had nonunion. The mean union time was 18.57±2.42 weeks. Femur fractures healed faster than tibia
(17.76±2.36 compared to 19±2.37 weeks, respectively, P=0.09). None of the patients suffered from infections or fistula.
The range of motion in hip and knee remained intact in approximately all patients. Malunion happened in 3 patients; 100
internal rotation in 1 patient; and 1cm limb shortening in 2 patients.
Conclusion: According to the result of this study, MIPO is a simple and effective method of fixation with a high rate
of union as well as minimal complications for comminuted fractures of long bones. Infection is rare, and malunion or
any deformity is infrequent. MIPO appears to be a promising and safe treatment alternative for comminuted fractures.


Main Subjects

1. Paige WA, Wood II GW. Fractures of lower extremity.
Terry Canale S, Beaty J, editors, Campbell’s operative
orthopedics. New York: Mosby; 2003.
2. Charles M. Court Brown Fractures of the tibia and
fibula. In: Robert WB, Charles CB, editors. Rockwood
& Wilkins fractures in adults. Philadelphia: Lippincott
Williams &Wilkins; 2006.
3. Collinge C, Sanders R, DiPasquale T. Treatment
of complex tibial periarticular fractures using
percutaneous techniques. Clin Orthop Relat Res.
2000; 375(1):69-77.
4. Rüedi TP, Murphy WM. AO principles of fracture
management. Davos: AO Publishing & Stuttgart; 2000.
5. Perren SM. Minimally invasive internal fixation
history, essence and potential of a new approach.
Injury. 2001; 32(Suppl 1):SA1-3.
6. Baumgaertel F, Buhl M, Rahn BA. Fracture healing
in biological plate osteosynthesis. Injury. 1998;
29(Suppl 3):C3-6.
7. Krettek C. Foreword: concepts of minimally invasive
plate osteosynthesis. Injury. 1997; 28(Suppl 1):A1-2.
8. Miclau T, Martin RE. The evolution of modern plate
osteosynthesis. Injury. 1997; 28(Suppl 1):A3-6.
9. Farouk O, Krettek C, Miclau T, Schandelmaier P, Guy P,
Tscherne H. Minimally invasive plate osteosynthesis
and vascularity: preliminary results of a cadaver
injection study. Injury. 1997; 28(Suppl 1):A7-12.
10. Javdan M, Andalib A, Fattahi F. Biological plating of
comminuted fractures of femur and tibia. J Res Med
Sci. 2007; 12(4):186-9.
11. Leunig M, Hertel R, Siebenrock KA, Ballmer FT,
Mast JW, Ganz R. The evolution of indirect reduction
techniques for the treatment of fractures. Clin Orthop
Relat Res. 2000; 375(1):7-14.
12. Burgess AR, Poka A, Brumback RJ, Flagle CL, Loeb PE,
Ebraheim NA. Pedestrian tibial injuries. J Trauma.
1987; 27(6):596-601.
13. Krettek C, Gerich T, Miclau TH. A minimally invasive
medial approach for proximal tibial fractures. Injury.
2001; 32(Suppl 1):SA4-13.

14. Helfet DL, Shonnard PY, Levine D, Borrelli J Jr. Minimally
invasive plate osteosynthesis of distal fractures of the
tibia. Injury. 1997; 28(Suppl 1):A42-7.
15. Rüedi TP, Sommer C, Leutenegger A. New techniques in
indirect reduction of long bone fractures. Clin Orthop
Relat Res. 1998; 347(1):27-34.
16. Vengsarkar N, Goregaonkar AB. Biological plating of
comminuted femoral fractures. Bombay Hosp J. 2001;
17. Krettek C, Schandelmaier P, Nliclau T, Tscherne H.
Minimally invasive percutaneous plate osteosynthesis
(MIPPO) using the DCS in proximal and distal femoral
fractures. Injury. 1997; 28(Suppl 1):A20-30.
18. Johnson EE. Combined direct and indirect reduction of
comminuted four-part intraarticular T-type fractures
of the distal femur. Clin Orthop Relat Res. 1988;
19. Ostrum RF, Geel C. Indirect reduction and internal
fixation of supracondylar femur fractures without
bone graft. J Orthop Trauma. 1995; 9(4):278-84.
20. Bolhofner BR, Carmen B, Clifford P. The results of
open reduction and internal fixation of distal femur
fractures using a biologic (indirect) reduction
technique. J Orthop Trauma. 1996; 10(6):372-7.
21. Agus H, Kalenderer Ö􀇆 , Eryanilmaz G, Ö􀇆 meroglu H.
Biological internal fixation of comminuted femur
shaft fractures by bridge plating in children. J Pediatr
Orthop. 2003; 23(2):184-9.
22. Baumgaertel F, Gotzen L. The” biological” plate
osteosynthesis in multi-fragment fractures of the paraarticular
femur. A prospective study. Unfallchirurg.
1994; 97(2):78-84.
23. Sarafan N, Marashinezhad SA, Mahdinasab SA, Sarami
A. Biological plating of comminuted femoral and tibial
fractures. Iran J Orthop Surg. 2005; 3(11):40-5.
24. Perren SM. Evolution of the internal fixation of long
bone fractures. The scientific basis of biological internal
fixation: choosing a new balance between stability and
biology. J Bone Joint Surg Br. 2002; 84(8):1093-110.
25. Fernandes HJ, Sakaki MH, Silva Jdos S, Reis FB, Zumiotti
AV. Comparative multicenter study of treatment of
multi-fragmented tibial diaphyseal fractures with
nonreamed interlocking nails and with bridging plates.
Clinics. 2006; 61(4):333-8.
26. Wisniewski TF, Radziejowski MJ. Minimally invasive
plating of high proximal tibial fractures unsuitable
for nailing. Program and abstracts of the 18th Annual
Meeting of the Orthopaedic Trauma Association,
Toronto, Ontario, Canada; 2002.
27. Wenda K, Runkel M, Degreif J, Rudig L. Minimally
invasive plate fixation in femoral shaft fractures.
Injury. 1997; 28(Suppl 1):A13-9.
28. Oh CW, Park BC, Kyung HS, Kim SJ, Kim HS, Lee SM, et
al. Percutaneous plating for unstable tibial fractures. J
Orthop Sci. 2003; 8(2):166-9.
29. Wong EW, Lee EW. Percutaneous plating of lower limb
long bone fractures. Injury. 2006; 37(6):543-53.
30. Xu H, Xue Z, Ding H, Qin H, An Z. Callus formation and
mineralization after fracture with different fixation
techniques: minimally invasive plate osteosynthesis
versus open reduction internal fixation. PloS One.
2015; 10(10):e0140037.
31. Jiamton C, Apivatthakakul T. The safety and feasibility
of minimally invasive plate osteosynthesis (MIPO)
on the medial side of the femur: a cadaveric injection
study. Injury. 2015; 46(11):2170-6.
32. Bhat R, Wani MM, Rashid S, Akhter N. Minimally
invasive percutaneous plate osteosynthesis for closed
distal tibial fractures: a consecutive study based
on 25 patients. Eur J Orthop Surg Traumatol. 2015;
33. Lill M, Attal R, Rudisch A, Wick MC, Blauth M, Lutz M.
Does MIPO of fractures of the distal femur result in more
rotational malalignment than ORIF? A retrospective
study. Eur J Trauma Emerg Surg. 2015; 42(6):733-740