Chronic Syndesmotic Instability Associated with a Complex Lesion of the Posterior Inferior Tibiofibular Ligament: Review, Case Report, and Surgical Report.

INTRODUCTION

Distal tibial fractures are difficult to manage due to their complex anatomy, subcutaneous location, and poor vascularity. Conventional open plating often causes soft tissue complications, while intramedullary nailing and external fixation have limitations in alignment and infection control. Minimally invasive percutaneous plate osteosynthesis (MIPPO) with anatomical distal tibial plates preserves periosteal blood supply and provides stable fixation. This study aimed to evaluate clinical and functional outcomes of distal tibial fractures treated by MIPPO.

MATERIALS AND

METHODS

A prospective case series was conducted at a tertiary care center from January 2022 to June 2024. Thirty-six patients were treated using MIPPO; 23 with a minimum of 12 months' follow-up were included. AO type 43-A2, 43-A3, and 43-C3 fractures and Gustilo-Anderson Grade I open fractures were included. Functional recovery was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score and the Foot and Ankle Ability Measure. Radiological union time and complications were also analyzed.

RESULTS

The mean patient age was 47.5 years; 65% of injuries were from road traffic accidents. The mean radiological union time was 11.4 weeks (range 5-17). Mean AOFAS scores improved from 39.6 preoperatively to 82.9 at 6 months and 87.7 at 12 months (P < 0.0001), with 90% achieving good-to-excellent outcomes. Complications included delayed union in three cases (13%), one superficial infection (4.3%), and one mild varus malunion (4.3%), all resolving without reoperation. There were no deep infections, implant failures, or non-unions.

DISCUSSION: MIPPO with anatomical locking plates provided excellent union rates and functional recovery, with minimal wound complications. Results compare favorably with previous series (union 11-16 weeks) and confirm that limited soft tissue dissection preserves vascularity and enhances healing. While small sample size and single-center design limit generalizability, outcomes reinforce MIPPO as a reliable fixation strategy for distal tibial fractures.

CONCLUSION

MIPPO using anatomical distal tibial plates is a safe, effective, and biologically sound fixation method. It achieves reliable union, early mobilization, and high functional scores with minimal complications. Future multicenter studies with longer follow-up are warranted for long-term validation.