From the Research
The surgical management of an old spiral midshaft tibial fracture using open reduction and internal fixation (ORIF) with plating is a complex procedure that requires careful planning and execution to achieve optimal outcomes in terms of morbidity, mortality, and quality of life. The procedure involves several critical steps, starting with patient positioning and preparation, including administration of appropriate anesthesia and prophylactic antibiotics, typically cefazolin 2g IV 1.
Preoperative Preparation
- The affected limb is prepped and draped in a sterile fashion.
- A tourniquet is applied but only inflated if necessary for visualization.
Surgical Approach
- An anteromedial approach is typically used, with an incision made along the subcutaneous border of the tibia.
- After dissection through subcutaneous tissue, the periosteum is incised and elevated to expose the fracture site.
Fracture Reduction and Fixation
- In old fractures, fibrous tissue and early callus must be removed to visualize the fracture pattern.
- The fracture is then reduced anatomically using reduction clamps or temporary K-wires.
- Once acceptable reduction is achieved (confirmed with fluoroscopy), a pre-contoured locking compression plate is selected and positioned on the anteromedial surface of the tibia.
- The plate should be of appropriate length to provide adequate fixation, typically with at least 3-4 screws on each side of the fracture.
- Screws are placed in a specific sequence: first, a compression screw across the fracture site to achieve interfragmentary compression, followed by locking screws proximally and distally.
Postoperative Care
- Fluoroscopic images in multiple planes confirm proper reduction and hardware placement.
- The wound is then irrigated, hemostasis achieved, and closure performed in layers with absorbable sutures for deep tissues and either nylon or staples for skin.
- A sterile dressing and splint are applied.
- Postoperatively, patients typically remain non-weight bearing for 6-8 weeks, with progressive weight bearing thereafter based on radiographic evidence of healing.
- Physical therapy is initiated early to maintain joint mobility and muscle strength.
Outcome
This procedure restores anatomical alignment and provides stable fixation, allowing for early mobilization while the fracture heals through both primary and secondary bone healing mechanisms. According to the most recent and highest quality study available 1, external fixation may offer some advantages in certain scenarios, but ORIF with plating remains a viable and effective treatment option for old spiral midshaft tibial fractures, especially when considering the need for stable fixation and early mobilization to optimize patient outcomes in terms of morbidity, mortality, and quality of life.