Minimally invasive plate osteosynthesis provides comparable functional outcomes and lower infection rates than ORIFMinimally invasive surgery shows potential benefits for lower leg fractures

BACKGROUND: Distal tibial fractures are challenging to manage owing to limited soft-tissue coverage and compromised blood supply. Minimally invasive plate osteosynthesis (MIPO) and open reduction and internal fixation (ORIF) are among the widely used surgical options, but the optimal approach remains unclear. MIPO preserves periosteal blood flow with smaller incisions, while ORIF offers direct visualisation but increases soft-tissue damage. With growing comparative evidence, an updated evaluation of these techniques is necessary. AIM: To compare the efficacy and safety of MIPO versus ORIF in adult patients with distal tibial fractures. METHODS: Following PRISMA guidelines and the Cochrane Handbook, we searched in PubMed, Embase, Cochrane, Scopus, and Web of Science till November 2025. Randomised trials and cohort studies comparing MIPO and ORIF were included. Data extraction was performed independently by two reviewers. Risk of bias was assessed using RoB 2 for RCTs and the Newcastle-Ottawa Scale for observational studies. Random-effects models were used to estimate pooled mean differences and odds ratios, and heterogeneity was assessed using I. Sensitivity and subgroup analyses were conducted by study design. RESULTS: Nine studies involving 530 patients met our inclusion criteria. No significant differences were found between MIPO and ORIF in AOFAS scores, union time, operative duration, hospital stay, return-to-work time, or major complications. MIPO showed trends toward shorter union time, reduced blood loss, and lower infection rates. Infection analysis showed a nonsignificant odds ratio (OR 0.57; 95% CI 0.24-1.33) but a statistically significant risk difference (RD -0.06; 95% CI -0.11 to -0.01), reflecting an absolute reduction of 4.6% with MIPO. Rates of malunion, delayed union, nonunion, and wound complications were similar between groups. CONCLUSIONS: MIPO and ORIF provide comparable functional and radiological outcomes for distal tibial fractures. MIPO offers modest advantages in soft-tissue preservation and infection risk. Surgical choice should be individualized on the basis of fracture characteristics and soft-tissue condition. Further multicenter randomized trials are needed.