Management of distal third tibial fractures: comparison of combined internal and external fixation with minimally invasive percutaneous plate osteosynthesis

Purpose The objective of this study was to compare combined internal and external fixation (CIEF) with minimally invasive percutaneous plate osteosynthesis (MIPPO) in the treatment of distal third tibial fractures, and explore the benefits and defects of these two techniques. Methods From April 2004 to February 2012, a total of 44 patients were randomised to operative stabilisation either by two closed titanium elastic nails combined with an external fixator (CIEF, 22) or by minimally invasive percutaneous osteosynthesis with a locking plate (MIPPO, 22). Pre-operative variables included the patients' age, sex, fracture side, cause of injury, Tscherne classification of soft tissue injury, fracture pattern, presence of open fracture and interval from injury to surgery. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, bone union time, time of recovery to work, the functional American Orthopaedic Foot and Ankle surgery (AOFAS) score and removal of hardware. Results There was no significant difference in the time to union, the time of recovery to work, function, alignment and total AOFAS scores between the two groups (P = 0.704, 0.835, 0.551, 0.716 and 0.212, respectively). The mean operating time and radiation time were longer in the MIPPO group than in the CIEF group (85.3 +/- 12.5 vs. 73.2 +/- 12.0 minutes, P = 0.002, and 3.1 +/- 1.5 vs. 2.1 +/- 1.2 minutes, P = 0.019, respectively). Wound complications were more common in the MIPPO group (18.2 % vs. 0 % with CIEF, P = 0.105). There was a trend for patients with MIPPO to have a higher incidence of ankle pain (31.8 % vs. 9.1 % with CIEF, P = 0.135). Painful implants were removed in 31.8 % of patients with MIPPO versus 9.1 % with CIEF (P = 0.135). Of the 165 self-tapping locking screws of the locking plates seven (four patients) were removed with some difficulty because of stripping of the hexagonal recess. Conclusions Our results indicated that both CIEF and MIPPO were all efficient methods for treating distal third tibial fractures. However, CIEF had the advantages of a shorter operating and radiation time, less wound complication and ankle pain, less secondary operations for implant removal and easier removal of the implants.