Comparative Study of Minimally Invasive Plate Osteosynthesis Versus Open Reduction and Internal Fixation in the...

Minimally invasive plate osteosynthesis (MIPO) has been proven to be better than open reduction and internal fixation (ORIF) for treating various long bone fractures. However, there are not many studies on distal fibula fracture treatment by MIPO. This study compares the clinical and radiological outcomes and quality of life of the MIPO with ORIF in the treatment of fractures of the distal fibula within a 6-month follow-up.

Patients undergoing MIPO (n = 27) and ORIF (n = 30) for distal fibula fractures (Danis-Weber type B and C) treatment from 2023 to 2024 were compared. All distal fibular fractures that were planned for surgical treatment (Danis-Weber type B and Danis-Weber type C) were incorporated (ORIF n = 30, MIPO n = 27). Post-operative pain was evaluated using a Visual Analog Scale (VAS), while quality of life was measured using SF-12 scores preoperatively and postoperatively. Complications such as infections and non-union were also assessed alongside radiological outcomes.

The complication rate was higher in the ORIF group (30%) in comparison with the MIPO group (22.2%). Specific complications such as non-union, infections, and post-operative pain at the 24th week were more frequent in the ORIF group. The MIPO group showed better physical and mental SF-12 scores at various follow-ups. In addition, tibiofibular overlap was significantly lower in the ORIF group, while other radiological measures were similar across the two groups.

This study has several limitations. First, it is retrospective in design, which inherently limits the ability to establish causal relationships between surgical technique and outcomes. Retrospective data collection may be influenced by recall bias, incomplete documentation, and selection bias, which may affect the reliability of findings. Second, the sample size is relatively small (n = 57; MIPO = 27, ORIF = 30), which restricts the statistical power to detect significant differences, especially for rare complications. Therefore, the results may not be generalizable to a broader population. Third, the follow-up duration is limited to 6 months. This period may be inadequate to evaluate long-term outcomes such as hardware failure, post-traumatic arthritis, late soft-tissue irritation, or the need for implant removal. Fourth, although the study focused on Danis-Weber Type B and C fractures, no further stratification or subgroup analysis was performed based on fracture complexity, comminution, or associated injuries, which could act as confounding variables. Fifth, the study lacks randomization, which can introduce selection bias. The decision to use MIPO or ORIF may have been influenced by surgeon preference or patient-specific factors such as soft-tissue condition or comorbidities. Sixth, the outcome assessors were not blinded to the surgical method, potentially introducing observer bias in evaluating clinical and radiological outcomes. Seventh, while VAS and SF-12 were used for quality-of-life and pain assessments, validated ankle-specific scores such as the Olerud-Molander Ankle score or the American Orthopaedic Foot and Ankle Society score were not included. Eighth, radiological evaluation relied solely on plain radiographs and did not compare with the contralateral side. Advanced imaging such as magnetic resonance imaging or computed tomography was not routinely used, which could underestimate syndesmotic injuries. Ninth, the study was conducted at a single tertiary care center. Thus, its findings may not be representative of outcomes in other institutions with differing resources and levels of surgical expertise. Tenth, no cost-effectiveness analysis was performed. Although MIPO may require specialized instruments and training, the economic viability of adopting this approach, especially in resource-limited settings, was not assessed. Eleventh, while a standardized rehabilitation protocol was followed, adherence to the protocol by patients was not reported, and could influence outcomes such as functional recovery and pain. Twelfth, no subgroup analysis was conducted based on patient age, comorbidities (e.g., diabetes, vascular disease), or bone quality (e.g., osteoporosis), all of which can impact healing and complication rates. Finally, many observed outcome differences were not statistically significant, possibly due to limited sample size, even though they may have clinical relevance. In addition, the study does not account for the surgeon's learning curve, which could have affected the operative efficiency or complication rates.

In this study, MIPO was better than ORIF in terms of the overall complication rate in the treatment of distal fibula fractures.