- Minimally invasive approach
The key concept of this approach is to preserve the soft-tissues and blood supply in the metaphyseal fracture area by not exposing them surgically. An entry site is developed over the distal tibia. The plate is then inserted from distal to proximal, through a tunnel between periosteum and intact overlying tissue.
The standard approach for the MIPO technique is medially. However, in selected cases with soft-tissue lesions on the medial side, an anterolateral approach can be used.
This MIPO approach is used for extraarticular type A fractures, or for simple, minimally displaced, intraarticular type C fractures. In the latter, the articular fracture component is not exposed, and is reduced either by indirect maneuvers using ligamentotaxis, or by the application of percutaneous reduction forceps, or directly by the percutaneously inserted lag screws.
Perform a straight, or slightly curved skin incision on the medial aspect of the distal tibia. The length of the incision varies from 3-5 cm, depending on the type of the planned plate. The incision stops distally at the tip of the medial malleolus.
For the insertion of the proximal screws in the diaphysis, separate stab incisions usually are sufficient.
Carry the incision straight across the subcutaneous fat, preserving the greater saphenous vein and saphenous nerve. They should be held anteriorly with a blunt retractor.
Advance the dissection down onto the periosteum which is completely preserved. In this anatomical space (epiperiosteal), the tunneling towards the diaphysis can usually easily be achieved with the blunt tip of the plate.
Pearl – mini arthrotomy
In case of a fracture extension to the medial malleolus, a small arthrotomy over the medial ankle joint aids removal of intraarticular osteochondral bone debris, inspection of the cartilage surface of the talar dome, and for the visual assessment of the reduction of the medial malleolus.