1. Minimally invasive osteosynthesis (MIO)―when to use it?
Published: September 2013
Reto Babst, CH
AOT Basic Principles Course

2. Learning outcomes
Describe the concept and principles of the MIPO technique
Specify the effect of implants on fracture stability
Discuss the bridge plating concept, including the biological and biomechanical priniciples
List the risks and benefits of MIPO

3. MIO principles Approach the bone far from the fracture zone
Indirect reduction of the fracture
Flexible fixation of the fracture
Secondary bone healing

4. Concept of minimally invasive plate osteosynthesis (MIPO)
Careful handling of soft tissue through small soft-tissue windows
Approach the bone far from fracture zone
Indirect reduction of the fracture (alignment, axis, and rotation)
Percutaneous direct reduction if needed
Maintaining reduction for C-arm control
Flexible fixation of the fracture

5. MIPO shaft Soft-tissue window: Far from the fracture site
Large enough to see, palpate, and fix the plate

6. MIPO fracture site
Little additional trauma if direct reduction is needed
Use instruments that leave small “footprints”

7. Bridge plating
Long plate to distribute forces (six holes on each side if possible)
Acts as an extramedullary splint
Fixation with bicortical screws, minimum three in each fragment
Provides relative stability

8. Bridge plating Comminuted fractures
Screws placed close to the fracture
Simple fractures
Screws 1–2 holes away from the fracture

9. Reduction in MIPO Indirect reduction by
Traction along the axis of the limb
Force application remote from the fracture site
Soft-tissue envelope helps reduction

10. Reduction in MIPO Direct reduction
Direct force applied at the fracture site
Percutaneously or mini opening

11. Maintaining reduction in MIPO
Traction table
External fixator
Forceps
Cerclage
Screw
Plate

12. Reduction control—needs a stable operative field
Adjuncts
Temporary fixation
K-wire, Schanz screw, screw, drill bit, clamps, plate
Cable
Prevent malunion

13. Indication for MIPO Periarticular fractures Joint level: anatomical
Shaft: aligned (length, axis, and rotation)
No nail possible
Narrow, deformed, or occupied canal (implant)
Open physis
Trauma load (ISS), pelvis
Soft-tissue conditions

14. Benefits Bone healing less disturbed Infection rate decreased
Less bone graft needed
Operation time decreased
Less pain
Faster rehabilitation
Cosmetic appearance

15. Risks Limited view Increased C-arm time Malunion Delayed/nonunion
Demanding technique with important learning curve

16. Take-home messages Approach through soft-tissue windows
Indirect reduction
Percutaneous direct reduction (tools)
Maintenance of reduction (x-ray control)
Elastic fixation
Selected indications