2. Introduction
• Minimal invasive plate osteosynthesis means that the plate is placed
through small incisions with as little dissection and stripping of the
soft tissue envelope as possible.
• This method gives priority to biology over mechanics
• It is also known as percutaneous, submuscular, Minimal incisional and
less-invasive plating.
• Both conventional as well as locking plates can be inserted through
this surgical technique.(MIPO locked plates are an improvement over
the conventional ones because they are non contact plates and don’t
need to be pressed over the bone to create a stable construct.)
3. MIPO STRATAGEM
1. Minimize skin incision
2. Access the bone through soft tissue windows
3. Handle deeper tissues gently
4. Curtail trauma to soft tissue and bone by indirect reduction
5. Lessen the fracture site damage in direct reduction.
6. Employ small footprint reduction tools
7. Deploy non contact plates (LCDCP), angular stable screws.
8. Monocortical screw fixaton only in strong bone.
4. Advantages
• It takes advantage of the indirect reduction technique.
• It safe guards blood supply as handling and direct reduction of intermediate
fragments are circumvented and direct insult over the area is avoided.
• It preserves periosteal blood supply and all other blood channels to the bone.
• Multiple collateral advantages of preserving the blood supply were noted such as
:-
1. Rapid bone healing
2. Early recovery
3. Reduced incidences of infection
4. Less bleeding during surgery
5. Reduced need for blood transfusion.
• Smaller incisions leads to improved cosmetics and less pain.
5. Pre-requisites.
1. Indirect closed reduction avoiding exposure of the fracture
2. Small incisions for Implant insertion
3. Implant that has minimal bone contact.
4. Elastic bridging of the fracture zone(principle of relative stability
stimulates call us formation)
5. Implants are used as pure splints.
6. Self tapping locking screws for monocortical or bicortical insertion
can be used .
6. Short comings and disadvantages
• As the stability of the fracture fixation depends on the stiffness of the
construct it is difficult to judge.
• It is complicated technique.
• Closed reduction and intraoperative control of alignment presumes a long
learning curve.
• Prederminted screw orientation could cause difficulties in screw insertion
such as penetration of articular surface.
• Reduction towards the plate may require special instruments .
• Excessive demands on Implants
• Delayed healing if wrong reduction and improper fixation.
7. Three main steps to MIPO
1. Approach
2. Reduction
3. Osteosynthesis
8. Reduction
• Achieving adequate reduction without inflicting additional trauma is
the primary goal of MIPO
• The key is to leave a small footprint or inflict least possible damage at
the fracture site
• Fractures can be reduced by two methods
1.Indirect :-forces and movements acting away from the fracture are
used to manipulate and reduce the fracture
2.Direct reduction:-achieved by applying forces and movements
directly in the vicinity of the fracture site.
9. Direct fracture reduction
• 1.Joystick metho :-
• A Schanz screw or Steinmann pin is mounted on a cannulated T
handle and is used as a joystick to control the bone fragments. The
Schanz screw is introduced through a stab incision .
• A bone hook can be used with a similar intent.
• Hohmann retractor is used as a bone lever .
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12. 2.Reduction by plate :-
A plate is placed on the side of the displaced fragment and the screws are applied ,
as the screws are tightened, the plate comes in contact with the displaced fragment
and pushes it to a reduced position and maintains it.
3.Reduction screw
A conventional cortex screw can be used as an aid to pull the bone towards the
plate.
4.Use of collinear reduction clamps
The clamp can be introduced through a small incision to grip the bone and plate
5.Reduction by cerclage wire
A cerclage wire is useful in maintaining a large wedge fragment and a severely
displaced oblique or spiral fracture fragment.
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16. Indirect fracture reduction
• 2.Direct reduction technique are used when individual fracture fragments need
not be anatomically reduced.
• This method is mainly used in management of diaphyseal fractures.
1.Manual traction:-
The application of traction is an important natural step in achieving reduction by
indirect means. The traction helps gain length and restores rotational and axial
malalignment.
2.Push and pull method:-
A bone spreader is useful to distract the fracture to gain length or achieve
reduction.
A plating holding clamp can apply comprehension in small bones.
A external fixator can be useful as a distractor. It is useful in applying traction across
a joint .
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18. 3.Handles for minimally invasive reduction:-
Schanz screws and conventional external fixator clamp and rod can be
assembled to form a useful tool for minimally invasive reduction.
4.Plate pusher and holder:-
A plate holder grips a plate at one end and has Excellent control of the
plate when it is under the soft tissue.A plate pusher temporarily moves
the plate against the bony cortex
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20. Useful tips for MIPO
1. Locating plate holes without fluoroscopy:-An identical plate can be
placed over the subcutaneous plate the holes marked.
2. Inserting a threaded drill guide:- insert a 4 mm kirschner wire as a
stylet through the threaded drill guide , locate the plate hole and
then slide down the drill guide and turn to screw it .
3. Measuring screw length:- On reaching the opposite cortex , stop
drilling and read the marking on the drill . Alternatively use a depth
gauge /measuring device.
4. MIPO requires multiple fluoroscopic checks during surgery to
ensure accuracy of reduction.
