History, definition, concept and basic principles

of minimally invasive osteosynthesis (MIO)

Reto Babst, CH AOTrauma Advances Course

History of MIPO

Stable osteosynthesis [1958]

Biological osteosynthesis [Mast et al, 1989]

Biological osteosynthesis
• Indirect reduction [Mast et al, 1989]
• Extramedullary splinting
• Endomedullary splinting
Biological osteosynthesis

C Kinast et al (1989) Clin Orthop Relat Res

Conventional Biological
osteosynthesis osteosynthesis

N 24 23

Bone graft 10 0

Weight bearing (Mt) 5.5 3.5

Delayed/nonunion 8 0

Infection 5 0
Conventional plating vs MIPO

C Krettek et al (1996) Unfallchirurg

Conventional plating vs MIPO

Osteosynthesis of distal femoral fractures [C Krettek et al 1996]

Standard MIPO
N=12 N=11

Primary cancellous bone 61 0

graft

Secondary cancellous 24 0
bone graft

Infection 7 0
Biological osteosynthesis vs MIPO

D Vogt 2002 OTA Abstract

Biological osteosynthesis MIPO

N=19 N=21
Malunion 0 6

Infection 2 0

Nonunion 1 0

Rev. 0 3
Plate evolution
LC-DCP PC-fix ‘94

LISS ‘97 Combination hole ‘99 LCP

Biological ORIF vs MIPO technique using a LCP
Minimally invasive working group of the AO
• Development of instruments for MIPO
• Defining and teaching of MIPO concepts
• Teaching MIPO principles and technique

• Empowerment to achieve the soft skills by practical exercises

- Standardized
- Reproducible manner
- Safe
MIPO tools
AO MIO courses
• 2004 Singapore 1st MIO Course

• 2005 Hong Kong/Davos

• 2006 Changmai/Davos

• 2007 Changmai/Minnesota/Davos

• 2008 Malaysia/Davos

• 2009 Romania

• 2010 New Delhi, India 07.07–10.07

Abbreviations
• MIS: minimally invasive surgery (access)

• MIO: minimally invasive osteosynthesis

• Minimally invasive nail osteosynthesis

• Minimally invasive fix ex osteosynthesis

• MIPO: minimally invasive plate osteosynthesis

Definition
Minimally invasive
• Access to the bone through soft-tissue windows
• Minimal trauma to the soft tissue and the bone by indirect
reduction
• Minimal additional trauma at the fracture site when direct
reduction is necessary
• Tools which cause “small footprints”
MIO joint
Soft tissue window
Big enough to achieve anatomical reduction
MIO shaft
Soft tissue window
Away from the fracture site, big enough to see or to palpate the
plate and the bone

Indirect reduction
MIO fracture site
Minimal additional trauma at the fracture site

Direct reduction
Osteosynthesis
Flexible fixation Stable fixation
Bridge plating Compression plating
MIPO definition of reduction
Indirect reduction
• Traction along axis of the limb
• Direct force application remote from the fracture site
• Soft tissue helps reduction (ligamentotaxis)

Direct reduction
• Direct force application at the fracture site
• Open or percutaneously
Indirect reduction by traction

• Manual traction

• AO distractor

• Push-pull forceps + direct force application

• Fracture table

• External fixator
Tools for indirect reduction

• Bolster

• Towel

• Joystick
Direct force application
• Plate remote from the fracture site

• Screw through the plate

• Collinear clamp with plate

Indication: diaphyseal fractures
• Restoration of length, axis, and rotation

• Correct position of the adjacent joints

• Individual fracture fragments need not

be anatomically reduced
Direct fracture reduction
• Anatomical reconstruction
• Absolute stability by rigid fixation
• Articular fractures
• Simple metaphyseal fractures
• Irreducible fractures
• Osteotomies, nonunions

Hazards:
• Too wide exposure
• Excessive periosteal stripping
Tools for reduction

• Hohmann

• Screw (lag screw) Force application directly

at the fracture site
• Collinear clamp

• Pointed reduction clamp

Open or closed (MIPO)

• Cerclage
Advantages of MIO
Biology
• Bone healing +
• Infection
• Bone graft
• Pain
• Faster rehabilitation
• Better cosmesis
Disadvantages of MIO
• Limited view

• Increased C-arm time

• Malunion

• Pseudarthrosis through diastasis

• Delayed union with flexible fixation in simple fractures

Summary

• Preoperative plan, critical case analysis

• Soft-tissue window: key is not length of incision

• Danger zones!

• Reduction indirect, direct reduction, if needed

• Reduction tools: minimal additional trauma

• The basic principles of ORIF remain the same!