Journal of Pediatric Orthopaedics - 2026-04-01 - Journal Article; Comparative Study
Comparative Outcomes of MIPO vs ESIN in Complex Pediatric Tibial Fractures: Diaphyseal AO 42B-C and Extra-articular Distal AO 43A2-A3.
Leonetti D, Giuca G, Marletta DA, Marrara G, Zampogna B, Nanni M, Sanzarello I
Topics
Key Takeaway
In complex pediatric tibial fractures (AO 42B-C and 43A2-A3), MIPO achieved radiographic union 5.2 weeks faster than ESIN (10.6 vs. 15.8 weeks, P<0.001) and eliminated unplanned reoperations (0% vs. 24%).
Summary Depth
Choose how much analysis to show on this article page.
Summary
This single-center retrospective cohort compared MIPO versus ESIN in skeletally immature patients aged 6–15 years with AO/OTA 42B-C diaphyseal or 43A2-A3 extra-articular distal tibial fractures over 7 years. MIPO produced faster union (10.6 vs. 15.8 weeks, P<0.001) and earlier return to full sport (13.3 vs. 20.6 weeks, P<0.001). Major complication rates were statistically similar (24% vs. 30%, P=0.41), but unplanned reoperations were exclusively in the ESIN group (0% vs. 24%).
Key Limitation
The 24% unplanned reoperation rate in the ESIN group likely reflects selection of more inherently unstable fractures for that technique, and without randomization or propensity matching, the superior MIPO outcomes cannot be attributed to the implant alone.
Original Abstract
BACKGROUND
Elastic Stable Intramedullary Nailing (ESIN) is a common treatment for pediatric tibial fractures, especially in standard diaphyseal fracture patterns and normal body mass index (BMI). However, ESIN may be technically limited in complex fracture morphologies (AO 42B-C, 43A2-A3) and in heavier children. Minimally Invasive Plate Osteosynthesis (MIPO), a technique widely embraced in adult orthopaedic trauma, may provide more stable fixation in these challenging scenarios through mini-incisions, indirect reduction strategies, and a stable "sliding plate" construct that preserves fracture biology.
OBJECTIVE
To compare clinical and radiographic outcomes of MIPO versus ESIN in diaphyseal AO 42B-C and extra-articular distal AO 43A2-A3 fractures.
METHODS
Single-center, retrospective cohort over 7 years, including skeletally immature patients (6 to 15 y) with diaphyseal AO/OTA 42B-C or extra-articular distal AO/OTA 43A2-A3 fractures. Intra-articular distal (43B-C) and physeal injuries were excluded. Primary outcomes were time to radiographic union and major complications (deep infection, loss of alignment requiring unplanned surgery, and implant bending/migration). Secondary outcomes included return to full sport, minor complications (superficial irritation/entry-site), residual deformity >5 degrees, and shortening >1 cm.
RESULTS
Fifty-eight children were analyzed (MIPO n=25; ESIN n=33). Union occurred sooner after MIPO (10.6±1.8 wk) than ESIN (15.8±2.5 wk) ( P <0.001). Return to full sport was earlier with MIPO (13.3±1.7 wk) versus ESIN (20.6±2.4 wk) ( P <0.001). Major complications occurred in 6/25 (24%) after MIPO and 10/33 (30%) after ESIN ( P =0.41); unplanned reoperations were 0/25 (0%) with MIPO and 8/33 (24%) with ESIN. Minor complications were comparable (40% vs. 42%, P =0.61), as was residual deformity >5 degrees (24% vs. 27%, P =0.564). Findings were directionally consistent in overweight children.
CONCLUSIONS
For complex extra-articular tibial fractures (42B-C; 43A2-A3), MIPO yielded faster union, earlier return to sport, and fewer reoperations than ESIN. Simple mid-diaphyseal fractures in lightweight children may still be managed nonoperatively or with standard ESIN.
LEVEL OF EVIDENCE
Level III.