This document discusses treatment options for segmental femoral fractures, specifically the option of modified minimally invasive plate osteosynthesis (MIPO). Segmental femoral fractures require careful treatment due to the severe soft tissue damage and risk of infection. Modified MIPO is proposed as an alternative to intramedullary nailing when it is contraindicated. The key steps of modified MIPO include making small incisions, indirect fracture reduction, stable fixation with locking plates while preserving blood supply, and early return of function through minimal soft tissue disruption. Complications can include malalignment, infection, and non-union if not performed carefully.

1. Treatment of Closed
Segmental femoral fracture;
the option of 'modified'
MIPO
Dr Okonkwo Chukwuebuka Augustine

2. Overview
• It takes a considerable life threatening force to
fracture a healthy femur, moreso segmental.
• Possible systemic compromise in airway ,
circulating volume and metabolic response further
compounds the accompanying severe soft tissue
breach in segmental fracture.
• Most Segmental fractures are traumatic, hence the
line this discussion will take.
• They will require individualized planning as their
osteosynthesis are difficult

3. Cont'd
• Options taken to fix the fracture given the fracture
pattern and orientation should not further tamper
with soft tissue and perfusion
• Surgical technique used must meet precise
specifications, allow light but solid assembly, sort
out loss of peripherality, reduce risk of infection
and allow for early rehabilitation
• Rkiba et al, 2021 - no consensus on best operating
technique

4. Cont'd
• T. Apivatthakakul et al, 2009 opined MIPO an
alternative where IM nailing I'd contraindicated
• 'Modification' of MIPO became necessary given the
fracture pattern, available instrumentation and
economic reality.

5. Options of treatment
• Non operative
• Operative
1. Intramedullary nail (reamed vs unreamed, solid vs
hollow)
2. Monocortical plate/screws and IM nail
3. Bicortical conventional plates and screws
4. Monocortical plate and Lag screw
5. MIPO
6. 'Modified' MIPO
7. External fixation

6. Treatment of index patient
• Started with ATLS protocol and interdisciplinary
care
• 1° survey - airway, breathing,circulation
• 2° survey - noted to have tongue laceration -
(sutured by OMFS team), thigh deformity and
avulsion injury of the L foot

7. Contd
• Treatment protocol as already outlined in case
summary
• Additional L thigh deformity splinted with Thomas
splint
• Counselled, choice of implant/options of care
discussed and consent obtained for operative
reduction
• Worked up, Anaesthetist consult dispatched

8. Surgery : 'modified' MIPO under
GA + ETT
• Patient was wheeled to theatre
• Pre op prophylactic antibiotics given
• Spinal+ epidural tried but failed, patient placed supine
• GA given
• Routine cleaning and draping
• Anterolateral thigh incision, lateral IM septum located ,
minimal dissection through muscles
• Findings noted
• Periosteum maximally preserved

9. Cont'd
• Distal fracture line reduced and fixed with distal
femoral anatomical plate
• Then the proximal with narrow DCP
• Drain inserted for collections, then anchored
• Skin closed with interrupted nylon 2/0 sutures
• Post op protocol initiated
• DVT prophylaxis
• Early physiotherapy

10. Immediate post op

11. 18 weeks post op

12. MIPO
• Historically, bone plating has been used in fracture
management since the 1800's
• Principles of fracture as emphasized by AO/ASIF
group recommended precise anatomic
reconstruction prior to plating at the price
extensive exposure and manipulation
• Continued research birthed minimally invasive
stabilization techniques
• MIPO involves a form of percutaneous plating
without extensive exposure of the fracture site

13. Goals
• Anatomic restoration of fracture surfaces without
rotational deformity

14. Principles of MIPO
• Minimal iatrogenic soft tissue fisrupto
• Indirect fracture reduction
• Appropriate stable fixation
• Early return of function
• Guided by preservation of blood supply with
minimal exposure of fracture site
• Union is by indirect formation of bridging callus and
remodeling

15. Contd
• Longer plates with fewer screw holes are preferred
• Locking plates are more desirable
• Near screws nearer to site and far screws farther
gives more stability

16. Indications

17. Contd

18. Contraindications

19. Technique
• Patient selection
• Implant selection - flouroscopy guidance where
necessary

20. Implant selection

21. Distal incision

22. Both incisions

23. Plate introduction

26. Fixation

27. Closure
• Sutures
• Staple
• Adhesive tapes

28. Advantages
• Good cosmetic appearance
• Reduced operation time
• Less risk for bacterial infection
• Less soft tissue trauma
• Reduced need for grafting
• Soft tissue envelope helps in reduction

29. Demerits
• Can be technically challenging
• Will require some form of image guidance

30. Complications
• Immediate
1. Hemorrhage
2. Post op pain
3. Fat embolism
• Delayed
1. Malalignement - commonest
2. Infection
3. DVT
• Late
1. Delayed union
2. No union
3. Bone defect

31. Prognosis
Healing is good with careful technique
Radiological evidence of callus 16-18 weeks
Consolidation at 30 months

32. Thank you

33. References