What is the step-by-step procedure for managing an old spiral fracture of the midshaft tibia using Open Reduction Internal Fixation (ORIF) with plating?

From the Research

The surgical management of an old spiral midshaft tibial fracture using open reduction and internal fixation (ORIF) with plating involves several critical steps, with the most recent and highest quality study 1 supporting the use of regional anesthesia for improved outcomes.

Preoperative Preparation

The patient is positioned supine on the operating table with a bump under the ipsilateral hip to facilitate access to the medial aspect of the tibia. After administering appropriate anesthesia, such as regional anesthesia which has been shown to be safe and effective for low-energy tibial plateau fractures 1, and preoperative antibiotics (typically 2g of cefazolin), the limb is prepped and draped in a sterile fashion.

Surgical Approach

An anteromedial approach is commonly used, with an incision made along the subcutaneous border of the tibia. The incision should be long enough to expose the fracture site and allow for plate placement, typically 10-15 cm. After dissecting through the subcutaneous tissue, the periosteum is carefully elevated to expose the fracture site. Fibrous tissue and callus at the fracture site must be removed to visualize the fracture pattern.

Reduction and Fixation

The medullary canal is then reamed on both sides of the fracture to restore patency. Reduction of the fracture is achieved using reduction clamps or a temporary external fixator, ensuring proper alignment, rotation, and length. Once anatomic reduction is confirmed with fluoroscopy, a pre-contoured locking compression plate (LCP) is positioned on the medial aspect of the tibia. The plate should be of appropriate length to provide adequate stability, typically with at least 3-4 screws on each side of the fracture. Locking screws are placed proximally and distally to secure the plate, with careful attention to avoid joint penetration.

Postoperative Care

After confirming plate and screw position with fluoroscopy, the wound is irrigated thoroughly. The periosteum and deep tissues are closed with absorbable sutures, followed by skin closure. A sterile dressing and a posterior splint are applied. Postoperatively, patients receive prophylactic antibiotics for 24 hours, appropriate pain management, and thromboprophylaxis. Weight-bearing is typically restricted for 6-12 weeks depending on fracture healing, with progressive weight-bearing as radiographic healing progresses. Physical therapy is initiated early to maintain joint mobility and muscle strength.

Key Considerations

• The use of regional anesthesia has been shown to be safe and effective for low-energy tibial plateau fractures, with improved outcomes compared to general anesthesia 1.
• The surgical approach and technique should be tailored to the individual patient's fracture pattern and anatomy.
• Postoperative care should prioritize pain management, thromboprophylaxis, and early mobilization to promote fracture healing and minimize complications.
• The most recent and highest quality study 1 supports the use of regional anesthesia for improved outcomes, and this should be considered in the management of old spiral midshaft tibial fractures.