Outcome of Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) using medial distal tibia anatomical locking compression plates for distal tibia fractures: A Prospective study

INTRODUCTION: Distal tibia fracture is a therapeutic challenge in modern orthopaedics. Due to fracture pattern, periarticular location, minimal soft tissue coverage, the surgical treatment is complex one. Various modality of surgical treatment such as closed intramedullary nailing, Open Reduction Internal Fixation with conventional plate osteosynthesis and external fixation has been tried so far. But none of them have good functional outcome but high complication rate (20-50%) Closed intramedullary nailing of distal tibia fracture can be a good option in AO type A fractures but the hourglass shape of the distal tibia does not allow anatomical reduction resulting in rotational and angular malalignment. Closed nailing is not an option, if the fracture line is less than 5cm from the articular margin (Type B, C fracture). External fixation is indicated in severe soft tissue injury or as a temporary stabilizing device. Pin tract infection,malreduction and joint stiffness are the drawbacks of external fixation. Though ORIF with conventional plating provides anatomical reduction and addressing the rotational,angular malreduction. It is associated with extensive soft tissue dissection and periosteal stripping which devitalize the fracture fragment resulting in nonunion, infections and wound dehiscence. AIM: To study the functional outcome of Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) using Medial Distal Tibia Anatomical Locking Compression Plates for Distal Tibial Fractures. MATERIALS AND METHODS: Prospective analyze of the outcome of minimally invasive percutaneous plate osteosynthesis(MIPPO) using medial distal tibia anatomical locking plate for distal tibia fractures & the functional outcome in these patients Inclusion Criteria: 1. Distal tibia fractures involving the lower one third of tibial Metaphysis and metaphyseo-diaphyseal junction AO/OTA classification type A,B,C distal tibia fratures, 2. Ruedi allgower type II&III pilon fractures, 3. simple fractures, 4. Age: 20-80 years. Exclusion Criteria : 1. Type I ruedi-allgower pilon fracture, 2. Compound fractures, 3. Delayed presentation of more than three weeks, 4. Non-union distal tibia fractures. RESULTS: Fifteen patients with distal tibia fractures were included in the study and were managed with Minimally Invasive Percutaneous Plate Osteosynthesis with medial distal tibia anatomical locking plates and . Among the the fifteen patients thirteen patients have had concurrent fibula fractures. ORIF of fibula was done in seven patients to maintain the limb alignment and it would help in indirect reduction of tibia fracture fragments. The mean age of the patients was 39.50 years. The study included 9 men (60%) and six women (40%); The distal tibia fracture was caused by a low-energy injury(fall) in 4 patients (26%) and by a high-energy injury in 11 patients (73%). The concurrent fibula fractures were in 13 patients (86%). Left side(60%) is more common than right(40%). The mean time interval between injury and surgery was 10.73 days. The mean operative time was 89.3 min. According to the fracture pattern, three(20%), five(13%), seven(53%) and nine (13%) holed plates were used. In seven patients, fibula fractures were stabilized with one third tubular plate with separate incision(53%).The mean rate of union was 19.4 weeks which is comparable to other studies. 72% of fractures united between 16 to 20 weeks. one patient had delayed union.(7%).The mean Olerud-Molander Ankle injury score improved significantly from 57.3 at the end of 3 months to 81.4 at the end of 6 months. CONCLUSION: In conclusion, the correct surgical technique (such as positioning the plate at correct offset after appropriate fracture reduction, which is confirmed by a final C-ARM check), and correct timing of surgery (which is evidenced by wrinkle sign), the anatomically precontoured medial distal tibia locking plate is suitable option for internal fixation of distal tibia fractures which may favour a better functional outcome and faster fracture healing. The complications like infections, malreduction, angular deformity are less frequent when the distal tibia fracture are treated with locking compression plates, compared to other techniques like conventional plates, intra medullary nails, external fixation, and conservative methods

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely