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