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

From the Guidelines

The management of an old midshaft tibial fracture requiring implant removal and subsequent open reduction internal fixation (ORIF) with plating involves a comprehensive surgical approach that prioritizes debridement, implant removal, and fracture stabilization to promote healing and prevent infection. The procedure begins with patient positioning in supine position on a radiolucent table after administering appropriate anesthesia. First, the surgeon makes an incision over the previous surgical site to expose and remove the existing implant, carefully preserving soft tissue and neurovascular structures, as emphasized in the study on fracture-related infection management 1.

Complete hardware removal is followed by thorough debridement of any nonviable tissue, fibrous material, or pseudomembrane at the fracture site, which is a crucial step in preventing infection and promoting healing, as highlighted in the study on the pathogenesis and management of fracture-related infection 1. The surgeon then freshens the fracture ends by removing sclerotic bone to expose healthy, bleeding bone surfaces, which promotes healing. Next, the fracture is reduced anatomically using reduction clamps or temporary K-wires.

Once satisfactory reduction is achieved and confirmed with fluoroscopy, a properly sized locking compression plate is selected and positioned on the anteromedial surface of the tibia. The plate is secured with a combination of locking and cortical screws, typically using at least 3-4 screws on each side of the fracture, to ensure stable fixation and promote healing, as suggested by the principles of fracture stability and consolidation 1. If there is significant bone loss, autologous bone grafting from the iliac crest may be necessary to fill defects and enhance healing.

After confirming proper alignment and fixation with intraoperative imaging, the wound is irrigated with normal saline, and layered closure is performed. Postoperatively, the patient receives prophylactic antibiotics, pain management, and thromboprophylaxis, with the goal of preventing infection and promoting a smooth recovery. Rehabilitation includes protected weight-bearing for 6-12 weeks with gradual progression based on radiographic evidence of healing.

Key considerations in this procedure include:

• Thorough debridement to prevent infection and promote healing
• Stable fixation to ensure fracture consolidation
• Autologous bone grafting to fill defects and enhance healing
• Prophylactic antibiotics to prevent infection
• Gradual progression of weight-bearing to promote healing and prevent complications, as supported by the study on fracture-related infection management 1.

By following this comprehensive approach, the surgeon can promote successful healing and prevent infection in patients with old midshaft tibial fractures requiring implant removal and ORIF with plating.

From the Research

Procedure for Old Fracture Midshaft Tibia Managed by Implant Removal and then ORIF with Plating

• The procedure for managing an old fracture of the midshaft tibia involves several steps, including implant removal and open reduction internal fixation (ORIF) with plating 2.
• The first step is to assess the fracture and determine the best course of treatment. This may involve imaging studies such as X-rays or CT scans to evaluate the fracture pattern and any associated soft tissue injuries 2.
• Once the decision has been made to proceed with implant removal and ORIF, the patient is taken to the operating room and prepared for surgery.
• The implant is removed, and the fracture site is exposed and cleaned to prepare it for ORIF 2.
• The ORIF procedure involves reducing the fracture and stabilizing it with internal fixation, such as plates and screws 2, 3.
• The goal of ORIF is to achieve anatomical reduction and stable fixation of the fracture, which is essential for promoting healing and preventing complications such as nonunion or malunion 2, 3.
• After the ORIF procedure, the patient is closely monitored for any complications, such as infection or hardware failure, and is followed up with regular imaging studies to assess the progress of healing 2, 3.

Considerations for Implant Removal and ORIF

• The decision to remove an implant and proceed with ORIF is based on several factors, including the type and severity of the fracture, the presence of any associated soft tissue injuries, and the patient's overall health status 2.
• The choice of implant and surgical approach may also depend on the specific characteristics of the fracture and the patient's anatomy 2, 3.
• For example, in cases where the fracture is located in the distal tibia, ORIF with medial plate fixation may be preferred over intramedullary nailing (IMN) due to the higher risk of nonunion and complications associated with IMN 3.
• However, the choice of surgical approach and implant should be individualized based on the specific needs and characteristics of each patient 2, 3.

Potential Complications and Outcomes

• The potential complications of implant removal and ORIF include infection, hardware failure, nonunion, and malunion 2, 3.
• The outcomes of ORIF for old fractures of the midshaft tibia can vary depending on several factors, including the severity of the fracture, the presence of any associated soft tissue injuries, and the patient's overall health status 2, 3.
• In general, ORIF can provide good outcomes in terms of promoting healing and preventing complications, but the specific results may vary depending on the individual characteristics of each patient 2, 3.