***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND Minimally invasive plate osteo synthesis ( MIPO ) is an established technique for fixation of fractures of the distal third tibia . Our study aim ed to manage intra articular and extraarticular fractures of the distal third tibia by the minimally invasive plate osteo synthesis technique and follow them prospect ively . Clinical and radiological outcomes were studied and clinical indications & efficacy of the procedure review ed . Though many studies on the subject have been done previously , these have been retrospective review s or small series . METHODS From May 2010 to May 2013 , 50 patients of closed distal tibial fractures were operated by MIPO technique with a distal tibial anatomical locking plate having 4.5/5 proximal and 3.5/4 distal screw holes . The follow up duration was for 3 years . RESULTS The mean fracture healing time was 21.4 weeks ( range 16 - 32 weeks ) and average AOFAS score 95.06 was out of a total possible 100 points . At last follow up , superficial infection occurred in 5 patients ( 10 % ) ; deep infection , implant failure and malunion in 1-patient each ( 2 % ) . CONCLUSION MIPO technique provides good , though slightly delayed bone healing and decreases incidence of nonunion and need for bone grafting . This technique should be used in distal tibia fractures where locked nailing can not be done like fractures with small distal metaphyseal fragments , vertical splits , markedly comminuted fractures and in fractures with intra-articular extension BACKGROUND The ideal treatment of distal tibial extra articular fractures remains controversial . Minimally invasive percutaneous plate osteo synthesis and intramedullary nailing are the two most commonly used methods . We did a prospect i ve r and omized controlled study to assess the functional outcome of distal tibial extra articular tibial fractures by comparing these treatment methods . MATERIAL S AND METHODS Sixty patients with distal tibial extra articular fractures were r and omly assigned to an IMN ( intramedullary nailing ) group and a MIPPO ( minimally invasive percutaneous plate osteo synthesis ) group . All patients were followed up for a period of one year . At final follow-up , clinical and radiological outcome was assessed by foot function index . Malunion , infection , implant removal , time to union and secondary interventions were compared between the two groups . The comparison of continuous variables was performed by using the Student t-test or Mann-Whitney U test in accordance with normality testing . A value of p less than 0.05 was considered statistically significant . RESULTS All patients were followed up for a period of one year . Time to callus formation was equal in both groups . There was no non-union in our series . Malunion was more common in the nailing group . The foot function index was similar in both groups . CONCLUSION MIPPO and intramedullary nailing are effective treatment options in the management of distal tibial extra particular fractures , with comparable functional outcomes Objective : To evaluate the clinical , radiographic , and functional outcomes of middle and distal third humeral shaft fractures treated with the minimally invasive percutaneous osteo synthesis ( MIPO ) . Design : Prospect i ve , single-center , nonconsecutive clinical series study . Setting : Skeletal trauma center of a university teaching hospital . Patients : Thirteen patients who were seen from May 2004 to October 2005 with an average age of 38.1 years ( range , 25 to 60 years ) form the basis of this study . Patients were obtained from a surgical data base of 1 surgeon . Intervention : The middle and the distal third humeral shaft fractures were reduced by closed means and fixed with long narrow 4.5-mm dynamic compression plates introduced through 2 small incisions away from the fracture sites and placed on the anterior aspect of the humerus . Main Outcome Measurements : Time to fracture healing and functional assessment s were assessed at an average follow-up of 12.5 months ( range , 7 to 19 months ) for the affected shoulders and elbows using the UCLA and Mayo elbow performance scoring systems , respectively . Results : All fractures united with a mean healing time of 16.2 weeks ( range , 12 to 32 years ) . There were no nonunions , radial nerve palsies , or implant failures . The UCLA scoring system showed excellent results in 7 cases ( 53.8 % ) and good results in 6 cases ( 46.2 % ) . Thirteen patients had excellent results of their elbow function when assessed with the Mayo elbow performance scoring system . Conclusion : Closed reduction and internal fixation of middle or distal third humeral shaft fractures using MIPO is a safe and effective surgical treatment method and an alternative option to open techniques This study compared the results of external fixation combined with limited open reduction and internal fixation ( EF + LORIF ) , minimally invasive percutaneous plate osteo synthesis ( MIPPO ) , and intramedullary nailing ( IMN ) for distal tibia fractures . A total of 84 patients with distal tibia shaft fractures were r and omized to operative stabilization using EF + LORIF ( 28 cases ) , MIPPO ( 28 cases ) , or IMN ( 28 cases ) . The 3 groups were comparable with respect to patient demographics . Data were collected on operative time and radiation time , union time , complications , time of recovery to work , secondary operations , and measured joint function using the American Orthopaedic Foot and Ankle Society ( AOFAS ) score . There was no significant difference in time to union , incidence of union status , time of recovery to work , and AOFAS scores among the 3 groups ( P>.05 ) . Mean operative time and radiation time in the MIPPO group were longer than those in the IMN or EF + LORIF groups ( P<.05 ) . Wound complications after MIPPO were more common compared with IMN or EF + LORIF ( P<.05 ) . Anterior knee pain occurred frequently after IMN ( 32.1 % ) , and irritation symptoms were encountered more frequently after MIPPO ( 46.4 % ) . Although EF + LORIF was associated with fewer secondary procedures vs MIPPO or IMN , it was related with more pin-tract infections ( 14.3 % ) . Findings indicated that EF + LORIF , MIPPO , and IMN all achieved similar good functional results . However , EF + LORIF had some advantages over MIPPO and IMN in reducing operative and radiation times , postoperative complications , and reoperation rate . [ Orthopedics . 2016 ; 39(4):e627-e633 . ] Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Introduction : The treatment of fractures of proximal and distal tibia is challenging , because of the limited soft tissue envelope and poor vascularity . The best treatment remains controversial and it depends on the fracture morphology , displacement and comminution . Treatment options vary from closed reduction and cast to open reduction and internal fixation with plate . Open reduction and internal fixation with plate can result in extensive dissection and tissue devitalization . We conducted a study on management of these fractures by biological osteo synthesis using Minimally Invasive Plate Osteo synthesis ( MIPO ) technique with preservation of osseous and soft tissue vascularity . Methods : We conducted a prospect i ve study on closed reduction and percutaneous plating in 30 cases ( mean age 42.7 years ; 22 males and 8 females ) of closed fractures of tibia . Among them 24 had proximal tibial fractures and 6 had distal tibial fractures . The mean time from injury to surgery was seven days . Results : The mean operative time was 72.6 minutes ( range : 55 - 90 minutes ) . Mean time for radiological union was 17 weeks ( range : 14 - 22 weeks ) . There was one superficial wound infection which resolved with daily dressings and one week of oral antibiotics . One patient developed a nonunion which required a bone grafting procedure . Conclusions : The satisfactory functional results and lack of soft tissue complications suggest that this method should be considered in periarticular fractures . Biological fixation of complex fractures gives stable as well as optimal internal fixation and complete recovery of limb function at an early stage with minimal risk of complications Purpose The purpose of this r and omized clinical trial is to compare intramedullary nailing ( IMN ) versus minimally invasive plate osteo synthesis ( MIPO ) for the treatment of extra-articular distal tibial shaft fractures . Material s and methods Twenty-five consecutive patients with distal extra-articular tibial fractures which were located between 4 and 12 cm from the tibial plafond ( AO 42A1 and 43A1 ) were r and omly assigned into IMN ( n : 10 ) or MIPO ( n : 15 ) treatment groups . All patients were followed for at least 1 year  . Foot function index , time to weight bearing , union time , duration of operation , length of incision , intra-operative blood loss , intra-operative fluoroscopy time , rotational and angular malalignment , rate of infection , secondary interventions and complications were compared between groups . Results All patients completed the trial and were followed with a mean of 23.1 ± 9.4 months ( range 12–52 ) . Foot function index , weight bearing time , union time , rate of malunion , rate of infection and rate of secondary interventions were all similar between groups ( p = 0.807 , p = 0.177 , p = 0.402 , p = 0.358 , p = 0.404 , p = 0.404 , respectively ) . Intra-operative blood loss , length of surgical incision , radiation time and rotational malalignment were higher in the IMN group ( p = 0.012 , p = 0.019 , p = 0.004 and p = 0.027 , respectively ) . Conclusions Results of our study showed that both treatment methods have similar therapeutic efficacy regarding functional outcomes and can be used safely for extra-articular distal tibial shaft fractures , and none of the techniques had a major advantage over the other Purpose A few studies focused on the methods of treatment for displaced distal tibial shaft fractures have been published , all of which compared two different methods . In this r and omized , prospect i ve study , we aim ed to compare minimally invasive plate osteo synthesis , locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures by assessing complications and secondary procedures . Methods From November 2002 to June 2012 , 137 skeletally mature patients with displaced distal tibial shaft fractures with or without fibula fracture were r and omized to be treated by minimally invasive plate osteo synthesis ( group A , n = 46 ) , locking intramedullary nail ( group B , n = 46 ) or external fixation combined with limited open reduction and absorbable internal fixation ( group C , n = 45 ) . Age , gender , mechanism of injury , fracture pattern and presence of open fracture were equally distributed among the three groups . Indexes for evaluation included hospital stay , operative time , time to radiographic union , union status , infection and the incidence of re-operation . Mazur ankle score was introduced for functional evaluation . Statistics Analysis System ( SAS ) 9.2 was used for analysis . Results A total of 121 patients were included in the final analysis ( group A 42 , group B 40 and group C 39 ) and evaluated after a mean of 14.8 months follow-up . There was no significant difference ( P > 0.05 ) in hospital stay , time to radiographic union and the incidence of union status among the three groups . Although group C was associated with less secondary procedures versus groups A and B , it was related with more pin tract infections ( 15.4 % ) . Anterior knee pain occurred frequently after locking intramedullary nailing ( 37.5 % ) and the irritation symptoms were more frequently encountered in group A ( 59.5 % ) . There was no difference in ankle function between the three methods after operation ( P > 0.05 ) . Conclusions We consider that the minimally invasive plate osteo synthesis , locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation techniques are all efficient methods for treating distal tibia fractures . With its wide indications , external fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication , good functional result and no local soft tissue irritation or implant removal Background : Extraarticular distal tibial fractures are among the most challenging fractures encountered by an orthopedician for treatment because of its subcutaneous location , poor blood supply and decreased muscular cover anteriorly , complications such as delayed union , nonunion , wound infection , and wound dehiscence are often seen as a great challenge to the surgeon . Minimally invasive plate osteo synthesis ( MIPO ) and intramedullary interlocking nail ( IMLN ) are two well-accepted and effective methods , but each has been historically related to complications . This study compares clinical and radiological outcome in extraarticular distal tibia fractures treated by intramedullary interlocking nail ( IMLN ) and minimally invasive plate osteo synthesis ( MIPO ) . Material s and Methods : 42 patients included in this study , 21 underwent IMLN and 21 were treated with MIPO who met the inclusion criteria and operated between June 2014 and May 2015 . Patients were followed up for clinical and radiological 
    Output:
    
Conclusions Compared to MIPPO , IMN had a significantly low risk of wound complications and associated with limited time for reunion .
Although the pooled functional outcomes of the two groups were controversial due to different evaluating scores , IMN was the preferred surgical technique than MIPPO for treating distal tibial fractures