대한족부족관절학회지 : 제 13 권제 2 호 2009 J Korean Foot Ankle Soc. Vol. 13. No. 2. pp.162-168, 2009 관동대학교의과대학명지병원정형외과학교실 Treatment of Distal Tibia Fracture using MIPPO Technique with Locking Compression Plate: Comparative Study of the Intraarticular Fracture and Extraarticular Fracture Soo-Tae Chung, M.D., Hyung-Soo Kim, M.D., Seung-Do Cha, M.D., Jeong-Hyun Yoo, M.D., Jai-Hyung Park, M.D., Joo-Hak Kim, M.D., Jin-Ha Jung, M.D. Department of Orthopaedic Surgery and Pathology, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea =Abstract= Purpose: To evaluate the efficiency of the minimally invasive percutaneous plate osteosynthesis (MIPPO) with locking compression plate (LCP) for distal tibial metaphyseal intra-articular fracture compared with extra-articular fracture. Materials and Methods: From February 2006 to June 2008, 21 patients with distal tibia metaphyseal intra-articular fracture and 20 patients with extra-articular fracture were treated operatively by MIPPO technique with LCP and followed for at least one year. In the group with intra-articular fracture, mean age was 48.85 years old and a mean follow-up was 15 months. In the other group with extra-articular fracture, mean age was 52.35 years old and a mean follow-up was 14.5 months. The type of fracture was evaluated using the AO/OTA classification and open-fractures were according to the Gustilo-And gron classification. Radiologic evaluation with fracture healing and tibial alignment, clinical evaluation with Olerud and Molander ankle score and restriction of motion were done for treatment. Results: According to AO/OTA classification, There were 21 type A, 15 type B, 5 type C. Average union time of the intra-articular fracture (type B, C) was 18.7 weeks. Average union time of the extra-articular fracture (type A) was 17.1 weeks. All fractures were healed without malunion. There were no difference of mean restriction angle between intra-articular fracture (ankle dorsiflexion was 3.57 degree, plantar-flexion was 5.95 degree) and extra-articular fracture (ankle dorsiflexion was 3 degree, plantar-flexion was 3.75 degree). There were no difference of Olerud and Molander ankle score between them as a mean score of intra-articular and extra-articular was 89.25, 91.25 each other. As a complication, there were 3 case of skin necrosis, 8 case of discomfortable skin tenting by plate and 1 superficial infection, but could be healed by conservative care. Conclusion: MIPPO technique, combined articular reduction, with LCP of distal tibial metaphyseal fracture was a good method with high functional recovery. Key Words: Distal tibial metaphyseal fracture, Locking compression plate (LCP), Minimal invasive plate percutaneous osteosynthesis (MIPPO) technique Address for correspondence Seung-Do Cha, M.D. Department of Orthopaedic Surgery, Myongji Hospital, Kwandong University College of Medicine, 697-24 Hwajeong-dong, Deokyanggu, Goyang-si, Gyeonggi-do, 412-270, Korea Tel: +82-31-810-6530 Fax: +82-31-810-6537 E-mail: bladeplate@hanmail.net. 서론원위부경골골절은고에너지손상에의한복잡골절과저에너지손상에의한나선상골절이나타나는경우가많고주위연부조직이적어개방성골절과순환장애로인한문제 - 162 -
점이흔히발생하며, 족관절과인접해있어서관절내골절이빈번하고, 치료후운동장애를일으키기쉽다. 원위부경골골절의수술적치료로는관혈적정복술및금속판고정술, 골수강내금속정고정술, 외고정술의방법등이있다 6,8,9). 전통적인관혈적정복및금속판내고정술은광범위한연부조직의절개와골막의박리로창상감염, 지연유합, 불유합의발생율이높으며 22,23,30) 골수강내금속정고정술은원위부의골편이작은경우와, 관절내골절이나복잡골절인경우충분한고정을얻을수없고, 외고정은핀감염과부정유합등의발생빈도가높다. 최근경골원위부골절을최소침습적금속판고정술을이용하여좋은결과를낸연구 14-16,20,26) 가많이발표되고있어, 저자들은원위부경골골절에대해관절내골절인경우최소절개를이용한관혈적정복후유관나사를고정하고, 관절외골절의경우는비관혈적정복후연부조직의손상을최소화하고금속판을삽입하여나사못으로고정하는최소침습적금속판고정수기를시행하였고그결과를임상적, 방사선학적으로분석하여보고하고자한다. 1. 연구대상및분류 대상및방법 2006 년 2 월부터 2008 년 6 월까지경골원위간단부이하 골절환자로본원에입원하여최소침습적경피적금속판고정술을이용하여치료하였던환자중 1년이상추시가가능하였던환자 41예를대상으로하였다. 관절외골절 (Fig. 1) 과관절내골절군 (Fig. 2) 으로나누었으며, 관절외골절의경우평균추시기간은 15개월 ( 범위, 12~23 개월 ) 이었으며, 남자가 10예, 여자가 10예였고연령은평균 52.35 세 ( 범위, 28~77 세 ) 였다. 관절내골절의경우평균추시기간은 14.5 개월 ( 범위, 12~19 개월 ) 이었으며, 남자가 15예, 여자가 6예였고연령은평균 48.85 세 ( 범위, 24~76 세 ) 였다. 32예에서비골골절이동반되었고, 이중 27예의외과골절에대해서는 1/3 관상금속판 (1/3 tubular plate) 을이용하여고정하였으며 5예의전위가경미한근위부비골골절에대해서는보존적치료를시행하였다. 총 21예에서관절내골절이있었고, 이경우모두외과골절이동반되었다. 관절골절면의전위가 1 mm이내인 7예에서는잠김나사가골절선을지나고정되도록하였으며, 이들을제외하고 14예에서경골의관절내골절에대해최소절개를통한유관나사못 (cannulated screw) 고정을시행하였다. AO/OTA 분류에의하면 A1형이 11예, A2형이 6예, A3형이 3예로관절외골절이 20예, B1형이 10예, B2형이 3예, B3형이 1예, C1형이 2예, C2형이 4 예, C3형이 1예로관절내골절이 21예였다. 비개방성골절이 34예, 개방성골절은 7예로각각관절외골절군에서 4예, 관절내골절군에서 3예였으며, Gustilo-Anderson 분류상 I형이 2예, II형이 5예였다 (Table 1, 2). 사용된내고정물은모든 A B C A B C Figure 1. (A) This radiograph shows preoperative X-ray of extraarticular fracture. (B) This radiograph shows postoperative X-ray of extra-articular fracture using MIPPO technique. (C) After 6 month, this radiograph shows complete bone union of fracture site. Figure 2. (A) This radiograph shows preoperative X-ray of intraarticular fracture. (B) In this postoperative X-ray, intra-articular fracture is fixed with locking screws and cannulated screws. (C) After 6 month, this radiograph shows bone union of fracture site. - 163 -
예에서잠김압박금속판 (LCP, distal medial tibia plate, Synthes, Swiss) 을이용하였으며, 수상후수술까지의기간은수상일로부터 0~7 일까지, 평균 5.6 일에수술을시행하였다. 2. 수술방법환자를전신마취또는척추마취하에방사선투과성수술대에앙와위로눕히고영상증폭기하에수술을시작하였다. 외과골절이동반된경우관혈적정복술및내부고정술을시행하여비골의길이를맞춘뒤, 전위가있는관절내골절의경우골절면의위치가외측에있을경우에는외과골절의수술절개면을이용하여전외방관절막을절개한뒤관절면을정복하였으며, 골절면의위치가내측에있을경우관절전내측의최소절개를통하여관절면을정복하고유관나사고정을시행하였다. 경골골절에대해피부바깥에서정복겸자를이용하여비관혈적정복후에, K-강선이나, 정복겸자로골절부의일시적인고정을유지한후 (Fig. 3), 적절한길이의금속판을경골내측면의피부에압박하여방사선투시경하에적절한위치를확인하고, 경골내과부위에 2 cm, 골절근위부골간단부에 2 cm 크기의최소피부절개후피부와피하층을경골로부터조심스럽게박리하고골막박리를 하지않은상태에서경골면을따라잠김압박금속판 (LCP, distal medial tibia plate, Synthes, Swiss) 을원위부에서근위부를향하여, 골막하로들어가지않도록주의하면서경피적으로삽입하였다 (Fig. 4). 금속판의원위부끝부위는경골내과의정측면에대해약간전방에위치하게하였고근위부위는경골내측면의중앙에위치하게하고, 골절에서근위부로네홀이상이되도록하였다. 방사선투시경하에금속판위치와골절정복된상태를확인하면서잠김나사못 (locking screw) 고정을경피적으로실시하였다 (Fig. 5). 정복후에만족스럽게정복이된경우일반나사를삽입하지않고내적외고정장치 (internal external fixation) 의개념으로잠김나사못으로만고정을하였으며, 정복후약간의전위나일반나사를이용하여골절면의압박이필요하다고생각되는경우에는일반나사를이용하여압박하거나골절편을금속판으로밀착시켜좀더정복하는방법으로고정을시행하였다. 수술종료전금속판의위치와정렬을재확인하고피부봉합후단하지석고부목고정을시행하였다. 3. 수술후처치및평가수술후 4주까지단하지석고고정을시행한뒤족관절운 T a b l e 1. Summary of Extra-Articular Fracture Case Case No Age/Gender (years) AO class Open Fx. type* OMA score Union time (weeks) Complications LOM(D/P) (degrees) 1 69/F A2 95 16 Skin irritation 5/0 2 64/F A1 95 16 Skin irritation 5/0 3 66/F A1 85 16 10/ 0 4 43/M A1 II 95 16 0/5 5 77/F A3 85 22 Skin necrosis 5/10 6 40/M A2 95 16 0/0 7 42/F A1 95 16 0/0 8 52/M A1 85 20 Wound infection 0/5 9 48/F A1 95 16 0/15 10 59/M A3 II 85 20 5/0 11 47/M A1 85 16 Skin irritation 5/15 12 38/F A2 I 85 20 Skin necrosis 5/15 13 51/M A3 II 95 18 5/0 14 59/F A1 95 16 0/0 15 52/M A2 95 16 5/0 16 29/F A1 95 16 5/0 17 57/M A2 95 18 0/0 18 66/M A1 95 16 Skin irritation 0/0 19 28/M A2 85 16 0/5 20 60/F A1 90 16 5/5 Mean 52.35 91.25 17.1 3/3.75 *Open Fx. type is according to Gustilo-Anderson classification; OMA, ankle score of Olerud-Molander; LOM(D/P) is limitation of motion (dorsiflexion and plantar flexion). - 164 -
T a b l e 2. Summary of Intra Articular Fracture Case Case No Age/Gender (years) AO class Open Fx. type* OMA score Union time (weeks) Complications LOM(D/P) (degrees) 1 53/M C1 80 16 Skin irritation 0/5 2 64/F C1 95 18 0/5 3 41/M B1 95 18 5/5 4 38/F C2 80 16 10/10 5 76/F B1 95 18 Skin irritation 0/5 6 47/F B1 95 20 0/15 7 42/M C3 I 80 22 5/10 8 33/M B1 II 95 18 10/5 9 49/F B2 80 20 5/0 10 31/M B1 95 20 0/0 11 58/M C2 II 70 24 Skin necrosis 0/20 12 24/M B3 85 18 5/5 13 28/M B1 85 20 5/5 14 40/M C2 90 20 10/10 15 47/M B2 95 18 0/5 16 52/M B1 90 20 5/5 17 53/F C2 95 20 5/10 18 56/M B1 95 18 5/5 19 57/M B1 95 16 5/0 20 61/M B1 90 16 Skin irritation 0/0 21 66/M B2 95 18 Skin irritation 0/0 Mean 48.85 89.28 18.76 3.57/5.95 *Open Fx. type is according to Gustilo-Anderson classification; OMA, ankle score of Olerud-Molander; LOM(D/P) is limitation of motion(dorsiflexion and plantar flexion) 동을시행하였으며관절외골절의경우 4주부터, 관절내골절의경우 6주부터목발과발목보조기를사용하여부분체중부하를시행하였다. 방사선학적골유합소견이보이면완전체중부하를시행하였고가장마지막추시일을기준으로임상적평가를시행하였다. 골절의유합은방사선학적으로전후및측면방사선사진상 4면중 3면이상에서골소주가통과하는것과체중부하시골절부에동통이없을때로판단하였고, 부정유합의기준으로는건측의방사선소견과비교하여 5 mm 이상단축이있을때나 5 이상의각변형이나회전변형이있을때부정유합이있다고판단하였다. 임상적평가는건측족근관절의운동범위를기준으로하여관절운동제한을측정하였고, 기능적평가를위해 Olerud 와 Molander 의족관절평가표 24) 를이용하여 90점이상을우수, 80~90 점을만족, 80점이하를불만족으로판정하였다. 관절내, 관절외골절을나누어각각의방사선적평가와임상적평가를시행하고두집단간항목의통계적유의성을 p< 0.05 를기준으로 paired student t-test 를통하여결정하였다 (Table 1, 2). 결과전례에서부정유합및불유합소견은보이지않았으며골유합시기는전체평균 17.95 주 ( 범위, 16~24 주 ) 이었고, 관절내골절의경우 18.76 주, 관절외골절의경우 17.1 주로관절내골절이평균 1.6주더늦게유합되었으며이는통계적으로유의하였다 (p=0.01). 족관절운동범위제한정도는건측과비교하였고, 관절내골절의경우족관절운동범위제한정도는평균족배굴곡제한 3.57, 평균족저굴곡제한 5.95 이었으며, 관절외골절의경우각각 3, 3.75 로나타났다. 관절내골절의경우관절운동제한이더심하였으나통계적으로유의하지는않았으며 (p=0.58), Olerud 와 Molander 의족관절평가표에의한족관절기능적평가에있어서, 관절내골절은평균 89.28 점, 관절외골절의경우 91.25 점으로관절외골절이더높은점수를보였으나통계적으로차이는없었다 (p>0.05). 관절외골절의경우 13예에서우수의소견을보였고, 관절내골절의경우 14예에서우수의소견을보였으나 1예에서불만족하였다. 불만족의경우는 AO분류 C2의관절내골절이며 II형의개방성골절로수술후개방부위의피부괴사로인하여족관절운동시기가 - 165 -
Figure 3. Temporary fixation with 2 K-wire and reduction clapm after close reduction is satisfied. Figure 5. This photograph shows postreduction state. 늦어져족저굴곡제한이 20도로측정되고골유합시기도 24주로늦은경우였다. 내고정물의실패로인한이차적술식을시행한경우는없었으며, 합병증으로 3예에서피부괴사를보였다. 이중 2예는개방성골절이었으며각각열상이있는위치인외과와경골원위부전내측부위에피부괴사가있었고, 1예는당뇨가합병된환자로외과수술부위에피부괴사를보였으나보존적치료로치유되었다. 1예에서표재성감염을보였으나항생제치료로호전되었고심부감염은발생하지않았으며, 금속판원위부의돌출로인한피부의불편감이 8예에서발생되었다. 고 찰 골절치료의방법에있어서 Baumgaertel 등 1) 은양의대퇴골을이용한실험을통해, 관혈적정복을통한견고한해부학적고정보다비관혈적정복을이용한교각금속판고정 Figure 4. Locking compression plate was inserted beneath the subcutaneous l ayer after cl ose reduction. 술 (bridging plate fixation) 의경우가골절간격의가교와가골형성이더빨리나타나고, 골절회복이 3주더빨리시작된다고보고하여, 비관혈적정복을통해골절부위의혈류손상을최소화한뒤고정하는생물학적고정을강조하였으며이러한개념을이용하여최소침습적경피적금속판삽입술이대퇴골골절, 경골근위부골절, 경골원위부골절등의여러부위골절에사용되어왔다. 경골원위부의경우, 전내면이피부직하조직이고, 관절주위라는특징으로인하여전통적인관혈적정복술및내부고정술식을사용시광범위한피부절개와골막박리등으로인하여피부괴사, 관절강직, 불유합, 부정유합, 골수염등의합병증이흔히발생할수있고 5,29,31), 골수강내금속정고정술은골간단부의분쇄골절이나관절면까지연결되는골절선이있을때사용하기가적절하지않으며, 외고정술의경우핀주위감염, 불유합, 관절강직등의합병증이발생한다 3,12,25). 이러한수술들의합병증을줄이기위해최소한의피부절개로연부조직손상을최소화하며혈액순환을높여골유합의확률을높이는방법으로최소침습적경피적금속판삽입술이시도되었으며 13) 이는골절부위의연부조직을박리하지않고인대신연술 (ligamentotaxis) 을이용하여간접적으로골정렬을맞춘뒤피하층을따라금속판을밀어넣어골절의근위부와원위부를나사못으로고정하는것으로, 조작이간편하고분쇄골절시에도각골절편의혈액순환차단을최소화하고골편의혈류와골형성을촉진하는골절의혈종을보존할수있어불유합의가능성을낮출수있는장점이있다 17,18). 최소침습적금속판고정술시골편을고정하기위한금속판은주로 LC-DCP (Low contact-dynamic compression plate), DCP (dynamic compression plate), T-plate, LCP 등이이용되고있는데, 일반적인금속판을이용하여내고정 - 166 -
을시행할때에는고정나사에의해골막이압박되어주위혈액순환에장애를줄수있으나 LC-DCP 는골막의접촉을최소화하여골외막의혈류를보존할수있으며 28), LCP 역시골막으로부터떨어져서고정되기때문에혈액순환을보존할수있어경피적금속판고정술의개념에적합하다고할수있겠다. 하지만 LCP 를제외하고, LC-DCP 를포함한다른금속판의경우골에대한정확한윤곽형성이골의정렬을좌우하기때문에윤곽형성이적절하지않은경우부정유합을발생시킬수있다. 이등 20) 은 DCP 를이용하여 13예의원위부경골골간단골절의치료결과 1예에서 6도의외반변형이합병증으로남았고, 이의이유에대해긴금속판의잘못된형상조작에의해비롯되었다고하며, 오등 28) 은 LC-DCP 를이용한 21예의원위부경골골간단골절의치료결과에서 1예의 10도내회전변형이있었고, 경골간부와원위부의금속판고정시금속판접촉면의비틀림이부족하여발생되었다고한다. Helfet 등 17) 은반관상금속판 (semitubular plate) 을이용한 20예의원위부경골골절에대한치료결과에서 5도이상의내반변형이 1예, 10도이상의후방각변형이 2예에서발생되었다. LCP 는골절부의수동적정복형태그대로를유지하여고정하기때문에, 금속판에의한골절정복의변형이없어부정정렬을예방할수있으며, 일종의내적외고정장치 (internal external fixator) 로서피질골과금속판사이의간격이형성되어골막의혈류를최대한보존할수있어생물학적고정원칙에가장부합한다고하겠다 10,11). 관절내골절의경우골절된관절면을해부학적위치에되도록정확히정복해주어야좋은결과를예측할수있기때문에정확한관절내골편의정복및고정을위해서는관절의노출을위한광범위한전내측절개를통한전통적인관혈적정복및내고정이사용되어왔는데 21,27), 관절내골절은대부분높은에너지에의해발생되어주위연부조직의손상이흔히동반되기때문에광범위한절개시상처부위의합병증, 치유과정중에생기는섬유화에의한관절운동의제한, 심부감염이 55% 까지보고되고있다 2,7,19,29). 이에연부조직손상을최소화하며관절내골절을정복할수있는수술적방법이요구되고있는데, 최소절개를이용한관절면의관혈적정복술을병행한최소침습적금속판고정술은이러한요구에부합한다고할수있다. 본연구에서관절외골절 20예, 관절내골절 21예에대해 LCP 를이용한경피적금속판고정술을시행하여모든경우에서부정유합없이골유합을얻을수있었으며 3예의피부괴사와 1예의피부감염을제외하면다른합병증은없었다. 관절외골절과관절내골절에대한 Olerud 와 Molander 의족관절평가수치와족관절운동범 위제한비교에서유의한차이를보이지않아관절내골절의경우에도최소절개를이용하여관절면을정복한뒤최소침습적금속판고정술을시행하는것이유용한술식임을확인할수있었다. 관절내골절이관절외골절에비해평균 1.6 주골유합이늦게되었고, 이는관절내골절의경우일부에서관절전면의절개를이용한관혈적정복술을시행하였기때문에골절주위조직의손상을주었기때문이라고생각된다. 대부분의환자들은최종추시관찰시족관절기능적평가에만족을보였고, 합병증으로피부괴사를보인 3예중 2예는개방성골절이었으며각각개방성골절에의한열상이있는위치인외과와경골원위부전내측부위에피부괴사가있어서괴사부위절제후, VAC (vacuum assisted closure) 을이용하여치유되었고, 1예는 77세의여자환자로당뇨가동반되어있었으며수상당시골절부위의심한부종및피부찰과상이있어, 7일간부종을가라앉기까지기다린뒤수술을시행하였으나외과부위의 3 15 mm 가량의표재성피부괴사를보였고보존적치료로치유되었다. 1예에서표재성감염을보였으나항생제치료뒤호전되었으며심부감염은발생하지않았다. LC-DCP 나 DCP 등은금속판의두께가두꺼워경골내측부에서금속판의돌출로인한문제가생기게되며 4) 본연구에사용된 LCP 의경우두께가얇아경골내측부의돌출을최소화할수있고, 내과측에위치한 3.5mm 원위부네홀은금속판의두께가더욱얇아서금속판의돌출로인한환자의불편감을최소화할수있는구조를갖고있으나, 다른연구들 14-16,20,26) 의경우와마찬가지로경골내측부에서금속판의돌출로인한불편이 8예있었는데, 총 41예중 16예의경우금속판원위부네홀중나사고정이필요없는 1개 ~3개의홀을절단한뒤사용하였으며이경우경골내측과금속판윤곽이잘맞았으며금속판돌출로인한불편감도없었던것을미루어볼때, 원위부골절편의고정에반드시필요한홀이아니라면금속판의원위부절단은환자의피부불편감을줄일수있을것으로생각된다. 원위경골골절은많은수에서비골골절이동반되며, 이럴경우비골에대한고정을시행하여야회전력에대한안정성을높일수있고 20), 경골원위부골편정복시최종골정렬상태에대한조정이가능하기때문에 18) 족관절기능을위해서는비골골절에대한해부학적정복및내고정이필요하다고하겠다. 저자들의경우에도총 32예에서원위부비골골절이동반되었으며이중 27예의골절에대하여해부학적정복및내고정술을시행하여안정성을더하였으며최종골정렬시도움이되었다. - 167 -
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