On the inside of the leg, the tibia, which is also called the shinbone, is a big, strong bone. The thigh bone is the second-biggest bone in the body and is very important for moving and supporting weight. In terms of anatomy, the tibia links the front of the knee to the back of the ankle. There is a syndesmosis between the tibia and fibula, which is made up of interosseous membrane. This structure makes the structure more stable and limits the movement between the two bones. As it is very close to the ankle joint and has to carry heavy physical loads, the distal tibia is very likely to get hurt.

In orthopedics, tibial fractures, especially those that happen in the last third of the shaft, are some of the most common injuries. These breaks usually happen because of high-energy trauma, like car crashes and sports injuries(2). Also, low-energy processes like falls and twisting injuries can cause fractures, especially in older people or people with osteoporosis whose bones aren't strong enough. Since the tibia is under the skin and doesn't have a lot of soft tissue covering it, it is more likely to break open and cause problems (3).

Fractures of the distal third of the tibia are a major public health issue because they happen so often and have a big effect on people's lives. These fractures are becoming more common around the world, especially in developing countries where more people are riding motorcycles and traffic conditions aren't safe enough, which leads to a lot of accidents(2, 4). In high-income countries, sports accidents are the most common cause of death, especially among young people who do high-impact activities. The impact of these fractures changes by region, depending on things like population growth, industrialization, and access to medical care.(2,4).

Traumatic distal third tibial shaft fractures are hard to treat because of the complicated anatomy and biomechanics of this area(7). The main issues come from the distal tibia's unique anatomy, which is made worse by the fact that both untreated and badly managed fractures can lead to complications(8).

Biomechanically and physically, the distal third of the tibial shaft is located in a unique way near the ankle joint. Because it's close to the ankle joint, it can be hard to get and stay in the right position during treatment(9). Small errors can change the biomechanics of the joint, which can change how you walk and raise your risk of long-term problems like osteoarthritis. Another big problem is that there isn't enough blood in this area. Periosteal and endosteal vessels bring blood to the distal tibia. These vessels are often damaged when the bone breaks. This change makes it harder for the bone to heal, which can lead to a delayed or failed union. Also, the tibia's place under the skin, especially in its distal third, means that it doesn't cover a lot of soft tissue.

A single centre, hospital-based, 1:1, prospective, comparative, interventional study researchers looked at and compared the results of intramedullary nailing (IMN) and minimally invasive percutaneous plate osteosynthesis (MIPPO) in treating people with extra-articular distal third tibial shaft fractures. It was possible to directly compare radiological and functional results with this method, and complications and the need for secondary interventions could also be seen in a controlled clinical setting.

Phase 1: Planning Phase (3 months) Preparation and submission of the research protocol for ethical clearance. Design of data collection forms and informed consent documents. Training of personnel involved in data collection and surgical interventions.

Phase 2: Participant Recruitment & Data Collection Phase (12 months)Recruitment of eligible participants based on inclusion and exclusion criteria Preoperative evaluation, including clinical, radiological, and laboratory assessments Surgical interventions performed under standard protocols Postoperative assessment and follow-up of patients at regular intervals.

Phase 3: Data Analysis & Report Writing (3 months) Compilation and verification of collected data. Statistical analysis of radiological and functional outcomes. Interpretation of results and comparison between IMN and MIPPO techniques. Preparation of the final thesis report and manuscript for publication.

Inclusion Criteria: The people who took part in the study met the following requirements:

1. Adults aged 18 years or older.
2. Patients diagnosed with closed, extra-articular distal third tibial shaft fractures (AO/OTA Type A).
3. Patients requiring surgical intervention for fracture stabilization.
4. Patients who provided written informed consent for participation in the study.

Exclusion Criteria: People were not allowed to take part in the study if any of the following were true:

• Open fractures (Gustilo-Anderson Grade II and III).
• Comminuted fractures requiring primary bone grafting.
• Pathological fractures (due to tumors or metabolic bone disease).
• Polytrauma patients with multiple fractures

Table 1: Distribution of Participants based on Age

The age distribution of the study participants. In the IMN group, most patients were in the 41–50 years age group (34.3%) followed by the 51–60 years group (27.1%). In the MIPPO group, the highest number of patients were in the 31–40 years age group (38.6%) followed by the 41–50 years group (18.6%). The mean age was 46.5 years in the IMN group and 48.9 years in the MIPPO group.

Table 2: Distribution of Participants based on Mode of Injury

The mode of injury. In the IMN group, the most common cause was fall (35.7%) followed by sports injury (22.9%) and road traffic accident (21.4%). In the MIPPO group, fall was also the most common cause (28.6%) followed by sports injury (27.1%) and road traffic accident (18.6%).

Table 3: Distribution of Participants based on Time to Full Weight Bearing

The time to full weight bearing. In the IMN group, most patients achieved full weight bearing at 10 weeks (27.1%) followed by 8 and 12 weeks (17.1% each). In the MIPPO group, the highest number achieved it at 9 weeks (21.4%) followed by 8 weeks (20%) and 12 weeks (18.6%). The mean duration was 11.9 ± 1.7 weeks in the IMN group and 8.9 ± 1.4 weeks in the MIPPO group. The difference was statistically significant with a p value of 0.002.

Table 4: Distribution of Participants based on Required Secondary Surgical Intervention

Additionally, the Pearson chi²(1) = 0.1187, and the P-value = 0.730.

The need for secondary surgical intervention. In the IMN group, 7.14% of patients required a secondary procedure while 92.9% did not. In the MIPPO group, 5.71% needed further surgery while 94.3% did not. The difference was not statistically significant (p = 0.730).

This study was done in the Department of Orthopaedics at Amaltas Institute of Medical Sciences, Dewas, Madhya Pradesh. The study included adult patients with extra-articular distal third tibial shaft fractures. These patients needed surgery for fracture fixation. The study included a total of 140 patients. Seventy patients were treated with intramedullary nailing. Seventy patients were treated with minimally invasive percutaneous plate osteosynthesis.

The main aim of the study was to compare the outcomes of intramedullary nailing and MIPPO. The study measured functional recovery, time to weight bearing, need for re-surgery, and postoperative complications. The research also looked at the radiological healing of the fractures. These outcomes were measured using a standard scoring system and follow-up X-rays(10).

This study is important because tibial fractures are common and often need surgery. Choosing the best surgical method can improve healing and reduce problems. The comparison between IMN and MIPPO is helpful for surgeons in deciding the better method. The findings of this study may guide treatment in future cases(11). It also opens the way for further research in similar clinical settings.

In the same way, Kapil et al. (2022) found that the MIPPO group had better early scores at 3 months. They found that the MIPPO group had a mean AOFAS score of 64.2, while the IMN group had a mean score of 59.1 (p < 0.05). Liu et al. (2024) also said that in the early follow-up time, patients who had plate fixation had higher AOFAS scores. At 3 months, their study found that the MIPO group had mean scores of 66.1 and the IMN group had mean scores of 61.5. In a study by Patel et al. (2024), the MIPPO group was able to walk more quickly and had higher functional results at the end of 12 weeks. The difference was also statistically important in their results (p = 0.041) (12).

Kapil et al. (2022) found a similar pattern in their study. They reported higher AOFAS scores in the MIPPO group (mean 87.6) than the IMN group (mean 81.2) at 6 months, with the difference being significant (p < 0.01). Liu et al. (2024) also observed better functional scores in the MIPO group at final follow-up(13). After looking at the data, they found that MIPO had better mid-term results, with mean scores of 89.2 and RTN scoring 84.1. After 6 months, Pasha et al. (2025) found that the average AOFAS score in the MIPPO group was 86.4, while it was only 79.5 in the IMN group (p = 0.005). This finding is similar to the current study.

Elnewishy et al. (2023), in a systematic review, concluded that MIPPO generally showed better long-term function than IMN in most included studies. Additionally, Patel et al. (2024) found that after 6 months, patients treated with MIPPO had significantly higher AOFAS scores than those treated with IMN, and fewer of them reported pain or trouble walking. Overall, these studies support the idea that MIPPO helps people with distal tibial fractures heal more quickly and effectively than IMN. In the present study, patients in the MIPPO group were able to start partial weight bearing earlier than those in the IMN group. The mean time to partial weight bearing was 6.4 ± 1.2 weeks in the MIPPO group compared to 7.8 ± 1.2 weeks in the IMN group(14). This difference was statistically significant (p = 0.004). In the MIPPO group, 18.6% started weight bearing by 4 weeks and 25.7% by 5 weeks. In contrast, in the IMN group, no patients started weight bearing by 4 weeks and only 22.9% by 5 weeks. A greater number of IMN patients began weight bearing after 7 weeks.

Most people in both groups were between the ages of 31 and 60. The average age in the MIPPO group was a little higher. Males were more commonly affected than females in both groups. The left side was more commonly injured in the IMN group while the right side was more common in the MIPPO group. Fall was the most common mode of injury in both groups followed by sports-related injuries. Type A1 fracture was the most common fracture type in both groups.

1. Bourne, M., Sinkler, M. A., & Murphy, P. B. “Anatomy, Bony Pelvis and Lower Limb: Tibia.” 29th South African Transport Conference (SATC 2010), Aug. 8, 2023, pp. 749–760. NCBI Bookshelf, https://www.ncbi.nlm.nih.gov/books/NBK526053/.
2. Larsen, P., Elsoe, R., Hansen, S. H., Graven-Nielsen, T., Laessoe, U., & Rasmussen, S. “Incidence and Epidemiology of Tibial Shaft Fractures.” Injury, vol. 46, no. 4, Apr. 2015, pp. 746–750. https://pubmed.ncbi.nlm.nih.gov/25636535/.
3. White, T. D., & Folkens, P. A. “Chapter 15 - Leg: Femur, Patella, Tibia, & Fibula.” The Human Bone Manual, edited by T. D. White and P. A. Folkens, Academic Press, 2005, pp. 255–286. https://www.sciencedirect.com/science/article/pii/B9780120884674500181.
4. Wennergren, D., Bergdahl, C., Ekelund, J., Juto, H., Sundfeldt, M., & Möller, M. “Epidemiology and Incidence of Tibia Fractures in the Swedish Fracture Register.” Injury, vol. 49, no. 11, Nov. 2018, pp. 2068–2074. https://pubmed.ncbi.nlm.nih.gov/30220634/.
5. Cunningham, C., Scheuer, L., & Black, S. “Chapter 12 - The Lower Limb.” Developmental Juvenile Osteology, 2nd ed., edited by C. Cunningham, L. Scheuer, and S. Black, Academic Press, 2016, pp. 385–472. https://www.sciencedirect.com/science/article/pii/B9780123821065000128.
6. Reátiga Aguilar, J., Rios, X., González Edery, E., De La Rosa, A., & Arzuza Ortega, L. “Epidemiological Characterization of Tibial Plateau Fractures.” Journal of Orthopaedic Surgery and Research, vol. 17, no. 1, 2022, p. 106. https://doi.org/10.1186/s13018-022-02988-8.
7. Milner, S. A., Davis, T. R. C., Kellam, J. F., & Court-Brown, C. M. “Long-Term Outcome After Tibial Shaft Fracture: Is Malunion Important?” Journal of Bone and Joint Surgery – American Volume, vol. 84-A, 2002, pp. 971–980.
8. Park, S., Ahn, J., Gee, A. O., Kuntz, A. F., & Esterhai, J. L. “Compartment Syndrome in Tibial Fractures.” Journal of Orthopaedic Trauma, vol. 23, no. 7, Aug. 2009, pp. 514–518.
9. Bode, G., Strohm, P. C., Südkamp, N. P., & Hammer, T. O. “Tibial Shaft Fractures – Management and Treatment Options. A Review of the Current Literature.” Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca, vol. 79, no. 6, 2012, pp. 499–505.
10. Neumann, M. V., Strohm, P. C., Reising, K., Zwingmann, J., Hammer, T. O., & Suedkamp, N. P. “Complications After Surgical Management of Distal Lower Leg Fractures.” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, vol. 24, no. 1, 2016, p. 146. https://doi.org/10.1186/s13049-016-0333-1.
11. Lua, J., Tan, V. H., Sivasubramanian, H., & Kwek, E. “Complications of Open Tibial Fracture Management: Risk Factors and Treatment.” Malaysian Orthopaedic Journal, vol. 11, no. 1, Mar. 2017, pp. 18–22.
12. Paluvadi, S. V., Lal, H., Mittal, D., & Vidyarthi, K. “Management of Fractures of the Distal Third Tibia by Minimally Invasive Plate Osteosynthesis – A Prospective Series of 50 Patients.” Journal of Clinical Orthopaedics and Trauma, vol. 5, no. 3, Sep. 2014, pp. 129–136.
13. Lai, T. C., & Fleming, J. J. “Minimally Invasive Plate Osteosynthesis for Distal Tibia Fractures.” Clinics in Podiatric Medicine and Surgery, vol. 35, no. 2, 2018, pp. 223–232. https://www.sciencedirect.com/science/article/pii/S0891842217301350.
14. Duan, X., Ma, A., Qiu, Y., Zhang, Y., Wang, Z., Zhang, X. “Intramedullary Nailing for Tibial Shaft Fractures in Adults.” Cochrane Database of Systematic Reviews, vol. 1, 2012, CD008241.