European Journal of Cardiovascular Medicine

Fractures of the tibial shaft represent one of the most frequent and clinically significant injuries encountered in orthopedic trauma. Accounting for a substantial portion of long bone fractures, these injuries are often the result of high-energy trauma such as road traffic accidents or falls from height, particularly in younger individuals, while low-energy injuries tend to occur in older adults with compromised bone quality [1]. Due to the tibia's subcutaneous location and limited soft tissue envelope, these fractures are prone to complications like wound infection, delayed healing, and compartment syndrome [2].

The ideal treatment of tibial shaft fractures should aim for early mobilization, anatomical alignment, functional restoration, and minimal soft tissue damage. Traditional surgical options include intramedullary interlocking nailing (IMIL), open reduction and internal fixation (ORIF) with plates and screws, and external fixation. While IMIL is often considered the gold standard due to its ability to provide rigid internal fixation and early weight-bearing, it is not without drawbacks. Common complications include malunion, anterior knee pain, and technical challenges such as achieving distal locking in comminuted or distal third fractures [3, 4]. Plating, though effective in achieving anatomical alignment, requires extensive soft tissue dissection and is associated with a higher risk of wound complications, especially in distal tibial fractures [5].

In recent years, the orthopedic community has increasingly embraced the concept of biologically friendly fracture management. Minimally invasive surgical techniques are gaining popularity as they aim to preserve the periosteal blood supply and fracture hematoma, both of which are critical for callus formation and fracture healing [6]. One such innovative approach is the Minimally Invasive Reduction and Osteosynthesis System (MIROS), which combines elastic intramedullary K-wire fixation with external clamps. MIROS represents a hybrid technique that provides elastic stability while eliminating the need for large incisions, power tools, or rigid implants.

The MIROS system enables closed reduction and stabilization of tibial shaft fractures through small percutaneous entry points, preserving soft tissue integrity and promoting rapid recovery. By utilizing flexible wires and a clamp-based external interface, it functions on principles of dynamic compression and micromotion that stimulate biological healing while maintaining mechanical alignment [7]. Its relatively low cost, reduced operating time, and shorter hospital stay also make it particularly appealing in resource-limited settings and among patients with comorbidities that complicate wound healing [8].

This study aims to evaluate the radiological and functional outcomes of tibial shaft fractures treated using the MIROS system, and to determine its advantages over conventional fixation techniques with respect to healing time, recovery, and complications.

This prospective observational study was conducted in the Department of Orthopedics, Government Medical College, over a one-year period from April 2022 to March 2023. Ethical clearance was obtained from the institutional ethics committee prior to the commencement of the study, and informed written consent was secured from all participants.

A total of 40 patients were recruited for the study. Eligibility criteria included patients aged 18 years and above, of either sex, presenting with closed fractures of the tibial shaft—defined as fractures involving the proximal third, middle third, or distal third of the diaphysis. Patients with open fractures, associated neurovascular injuries, polytrauma, pathological fractures, or those medically unfit for surgery were excluded. Individuals who were unwilling or unable to comply with postoperative follow-up were also not considered for inclusion.

All patients underwent standard preoperative evaluation, including radiographs in anteroposterior and lateral views. In complex or segmental fractures, computed tomography (CT) was performed to assess intra-articular extension. The decision to use MIROS fixation was made in consultation with the surgical team, and the procedure was carried out under regional anesthesia—either spinal, epidural, or a combination of both.

The MIROS system utilizes elastic, beveled-tip Kirschner wires (K-wires) inserted through metaphyseal entry points under fluoroscopic guidance. Typically, 2.5 mm or 3 mm diameter wires were used depending on the patient's bone dimensions. Once fracture reduction was confirmed via C-arm, K-wires were introduced manually using the MIROS spindle without the need for power tools. The wires were advanced into the medullary canal with gentle rotational movements, and their external ends were secured using lightweight Tangari clamps. This configuration formed a stable, elastic construct resembling a suspension bridge, promoting dynamic compression and micromotion at the fracture site.

Postoperatively, the construct was evaluated intraoperatively for stability and alignment. Pin entry sites were cleaned and covered with sterile dressings. Patients were encouraged to initiate range of motion exercises for the knee and ankle from the first postoperative day. Partial weight-bearing was permitted in stable constructs as early as the second postoperative day, progressing to full weight-bearing based on clinical and radiological evidence of fracture consolidation.

Patients were followed up at the 3rd, 6th, 12th, and 24th weeks postoperatively. At each visit, clinical assessment included evaluation for pain, deformity, gait abnormalities, limb length discrepancy, joint stiffness, and pin site complications. Radiographic assessment was performed to monitor progression of callus formation and confirm union. Functional outcomes were assessed using the Johner and Wruhs criteria, which evaluate factors such as pain, gait, range of motion, and radiological alignment.

A total of 40 patients with closed tibial shaft fractures were included in this study. The mean age of the patients was 46.2 years, indicating that mid-adult and older individuals were most commonly affected. Males predominated the study population, accounting for 65% of cases, while females made up the remaining 35%. The right side was more frequently involved (55%) than the left (45%), although the distribution was relatively balanced. Road traffic accidents (RTAs) emerged as the most common cause of injury, accounting for 70% of the fractures, followed by accidental falls (22.5%) and other miscellaneous causes such as sports injuries and direct trauma (7.5%).

Table 1: Demographic and Clinical Profile

Regarding the anatomical distribution of fractures, the distal third of the tibial shaft was the most commonly involved site, representing 55% of cases. This was followed by midshaft fractures at 27.5% and proximal third fractures at 17.5%. The higher frequency of distal third involvement may reflect the pattern of forces sustained during vehicular trauma and ground-level falls.

Table 2: Fracture Distribution

The mean operative time required for MIROS fixation was 26.4 ± 3.1 minutes, suggesting a relatively short surgical duration. The average length of hospital stay was also modest, at 6.9 ± 1.3 days. Radiological union was achieved in a mean of 15.8 ± 1.7 weeks, demonstrating a favorable healing profile when compared to traditional internal fixation methods.

Table 3: Operative Metrics and Union

Functional outcomes were assessed using the Johner and Wruhs criteria at the final follow-up. The results were encouraging, with 62.5% of patients graded as having excellent outcomes and an additional 27.5% achieving good outcomes. A small proportion (10%) were classified as fair, and there were no cases with poor results. These findings highlight the effectiveness of MIROS in restoring functional capacity following tibial shaft fractures.

Table 4: Functional Outcomes (Johner and Wruhs Criteria)

Complication rates were low overall. Mild pin site infections occurred in 12.5% of cases, all of which were managed conservatively without requiring removal of the implant or readmission. Delayed union was observed in 5% of patients, but no cases of nonunion or deep infection were recorded during the follow-up period. Importantly, there were no incidences of implant loosening or mechanical failure.

Table 5: Complications

The timeline for return to full weight bearing (FWB) was also analyzed. Nearly half of the patients (45%) were able to achieve FWB within 6 to 8 weeks postoperatively. A further 30% did so between 9 and 10 weeks, while 15% and 10% achieved full weight bearing at 11–12 weeks and beyond 12 weeks, respectively. This pattern reflects the early stability provided by the MIROS construct and supports its role in facilitating prompt rehabilitation.

Table 6: Time to Full Weight Bearing (FWB)

This prospective observational study evaluated the clinical, radiological, and functional outcomes of MIROS fixation in tibial shaft fractures. The mean age of patients in our study was 46.2 years. This is comparable to the study by Yih-Shiunn Lee et al. [9], who reported a mean age of 43.1 years in their comparison of unlocked and interlocked intramedullary nails for tibial fractures. Similarly, Nork et al[10]. found the average age to be 42 years in patients undergoing nailing for distal metaphyseal fractures of the tibia. Our male predominance (65%) also aligns with data from Mc.Burnie et al[11], who observed male incidence of 81.3% in their study of tibial shaft fractures.

The average time to radiological union in our study was 15.8 weeks. This is consistent with the results of Mc.Burnie et al. [11], who reported a mean union time of 16.7 weeks following closed intramedullary tibial nailing.Boneet al. [12] reported slightly longer union durations averaging 19 weeks for patients treated with reamed intramedullary nails. The relatively shorter healing time seen in our MIROS series may be attributed to its minimally invasive, biologically conserving technique, which avoids periosteal stripping and preserves fracture hematoma.

The average operative time in our study was 26.4 minutes, which is considerably less than what is reported in studies involving conventional nailing or plating. Beebe et al. [13] noted average operative times exceeding 45 minutes in their study on intramedullary tibial nailing. Likewise, Papadakis et al [8]. reported mean operative times of 53 minutes in their series using hybrid external fixation for distal tibial fractures. The reduced operative duration in our study likely reflects the simplicity and efficiency of the MIROS system, which eliminates the need for large incisions, complex instrumentation, and power tools.

Hospital stay in our study averaged 6.9 days, a duration notably shorter than in studies employing open reduction techniques. Toms et al. [14], in their systematic review of locking plate osteosynthesis, documented hospital stays of 10–14 days in cases complicated by wound issues. The shorter hospitalization observed with MIROS reflects both its minimally invasive nature and early initiation of rehabilitation protocols.

Functional outcomes in our study were highly favorable, with 62.5% of patients achieving excellent results, 27.5% good, and 10% fair as per Johner and Wruhs criteria. These results compare well with those reported by Marco Tangari et al. [15], who found over 85% good to excellent outcomes in patients treated with Delta synthesis — a conceptually similar elastic fixation technique. Mahmood et al. [16] also reported excellent or good results in 86% of patients managed with expert tibial nailing for distal fractures, which is comparable to the 90% excellent/good outcome rate in our series.

In terms of complications, we observed mild pin site infections in 12.5% of cases, all of which responded to conservative measures. No cases of nonunion, implant failure, or deep infection were noted. These findings are favorable when compared to Barei et al. [17], who reported deep infections in 8% and nonunion in 5.6% of patients with high-energy tibial plateau fractures treated with internal fixation. The MIROS system, with its external clamping and percutaneous wire technique, avoids many of the soft tissue complications associated with open surgery.

Early weight-bearing is a critical goal in tibial fracture management. In our study, 45% of patients achieved full weight bearing by 6–8 weeks, and 75% by the 10th week. Vallier et al. [18] reported that patients treated with intramedullary nailing for distal tibial fractures were typically mobilized later, with full weight-bearing delayed beyond 12 weeks in many cases. The earlier weight-bearing seen with MIROS may be due to the dynamic elastic stability it provides, which facilitates micromotion and callus formation.

The present study demonstrates that the Minimally Invasive Reduction and Osteosynthesis System (MIROS) is a safe, effective, and biologically favorable method for managing tibial shaft fractures. The system offers several advantages over conventional fixation techniques, including shorter operative time, minimal soft tissue disruption, early mobilization, and reduced complication rates.

Radiological union was achieved in a mean of 15.8 weeks, and a significant proportion of patients (90%) had excellent to good functional outcomes by six months. The dynamic elastic stability offered by MIROS promotes early weight bearing and preserves fracture biology, particularly benefiting patients with distal third tibial fractures or those at risk for wound-related complications.

Given its clinical benefits, simplicity, and cost-effectiveness, MIROS should be considered a valuable alternative to traditional internal fixation methods, especially in settings where minimizing surgical trauma and expediting recovery are key treatment goals.

Acknowledgements: The authors would like to express their gratitude towards the staff of department of orthopedics for their assistance in conducting this study.

Conflicts of interest: None declared.

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